Pain dominates measurements of elbow function and health status

High correlation of the subjective elbow value with Mayo Elbow Performance Score and Oxford Elbow Score in patients with elbow dislocation

Background

The purpose of this study was to analyze the correlation of the Subjective Elbow Value (SEV) with 2 widely used elbow scoring systems: Mayo Elbow Performance Score (MEPS) and Oxford Elbow Score (OES) in patients following elbow dislocation.

Methods

In this retrospective single-center study, patients who sustained an elbow dislocation between January 2008 and December 2019 and were at least 2 years out from injury were included. SEV, OES and MEPS were assessed and statistical correlation was calculated using Pearson's correlation coefficient.

Results

A total of 114 patients (61 male, 53 female) with a mean age of 47.1 years (range, 16-70) were analyzed following elbow dislocation. The mean SEV was 87.4% (95% confidence interval (CI) 84.2-90.7), mean MEPS was 88.1 (95% CI 85.1-91.0) points and mean OES was 40.0 (95% CI 38.4-41.7) points. Both MEPS (r = 0.710, P < .001), and OES (r = 0.764, P < .001) demonstrated high correlation with the SEV.

Conclusion

This study demonstrates that the SEV is a valid tool to assess overall status of the elbow in patients following elbow dislocations and presents an expressive but easy to perform addition to more complex scoring systems.

Reliability, validity and critical appraisal of the cross-cultural adapted German version of the Mayo Elbow Performance Score (MEPS-G)

Background

The Mayo Elbow Performance Score (MEPS) is a rating system consisting of four dimensions to evaluate elbow performance. It is a common tool for assessment of elbow impairments worldwide. We determined the validity and reliability of its German version (MEPS-G) after cross-cultural adaptation.

Methods

Six investigators examined 57 patients with elbow pathologies. The MEPS-G was compared to validated elbow scores such as the German versions of DASH, the Oxford Elbow Score, pain level and subjective elbow performance on a VAS. Inter-rater reliability (IRR) and validity of the score and its dimensions were also reviewed. Verification was performed using the intraclass correlation coefficient (ICC), the prevalence and bias with adjusted Kappa (PABAK) and the Spearman correlation.

Results

The IRR of the MEPS-G score was moderate (ICC (2.1) = 0.65). The IRR of the four individual dimensions was moderate to high (K_PABAK = 0.55 -0.81). Validity for the sum score (r = 0.52–0.65) and the dimensions pain (r = 0.53–0.62), range of motion (r = 0.7) and stability (r = − 0.61) was verified. The function subscale reached insufficient validity (r = 0.15–0.39).

Conclusion

The MEPS-G is not sufficiently valid, which is consistent with its English version. The patient-based dimensions were a weakness, demonstrating high risk of bias. There is no general recommendation for the utilization of the MEPS-G as outcome measurement for patients with elbow pathologies.

Understanding barriers and facilitators to implementation of psychosocial care within orthopedic trauma centers: a qualitative study with multidisciplinary stakeholders from geographically diverse settings

Background

Psychosocial factors are pivotal in recovery after acute orthopedic traumatic injuries. Addressing psychosocial factors is an important opportunity for preventing persistent pain and disability. We aim to identify barriers and facilitators to the implementation of psychosocial care within outpatient orthopedic trauma settings using the Consolidated Framework for Implementation Research (CFIR) and Proctor’s taxonomy of implementation outcomes, and to provide implementation strategies derived from qualitative data and supplemented by the Expert Recommendations for Implementing Change.

Methods

We conducted live video qualitative focus groups, exit interviews and individual interviews with stakeholders within 3 geographically diverse level 1 trauma settings (N = 79; 20 attendings, 28 residents, 10 nurses, 13 medical assistants, 5 physical therapists/social workers, and 3 fellows) at 3 trauma centers in Texas, Kentucky, and Massachusetts. We used directed and conventional content analyses to derive information on barriers, facilitators, and implementation strategies within 26 CFIR constructs nested within 3 relevant Proctor outcomes of acceptability, appropriateness, and feasibility.

Results

Stakeholders noted that implementing psychosocial care within their practice can be acceptable, appropriate, and feasible. Many perceived integrated psychosocial care as crucial for preventing persistent pain and reducing provider burden, noting they lack the time and specialized training to address patients’ psychosocial needs. Providers suggested strategies for integrating psychosocial care within orthopedic settings, including obtaining buy-in from leadership, providing concise and data-driven education to providers, bypassing stigma, and flexibly adapting to fast-paced clinics.

Conclusions

Results provide a blueprint for successful implementation of psychosocial care in orthopedic trauma settings, with important implications for prevention of persistent pain and disability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00208-8.

Analysis of Factors Affecting Return to Work After Surgical Treatment in Patients with AO Type C Distal Humerus Fractures

BACKGROUND

The purpose of this study is to evaluate the functional results of distal humerus fractures which were treated by open reduction and fixation with pre-contoured angular stable plates in young patients, and investigate whether the patients could return to their pre-injury work and patients' financial conditions while they were not working.

MATERIALS AND METHODS

The data of 48 patients, ages between 18 and 55 years, working in a job and having AO/OTA type C distal humerus fracture were retrospectively evaluated. Mayo Elbow Performance Score (MEPS) was used to determine functional results. Postoperative radiographs were evaluated to determine the rate of union, degenerative changes, malunion and heterotopic ossification. Financial outcome form was constituted by the authors and the patients asked whether she/he could return to their pre-injury works after treatment finished and the financial status of the patients during the treatment and after the treatment.

RESULTS

The mean flexion-extension arc was 114° ± 12°(range 85°-135°) and the mean MEPS score was 85 ± 11(range 65-100). The average time to return to work was 6.5 ± 2.4 months (3-12 months). AO type C2 and C3 fractures and heterotopic ossification negatively affected the functional results and also adversely affected the patients' return to their pre-injury works. 38 (79%) patients returned to pre-injury work and 29 (76%) of them started to work at the same position before the fracture occured. Nine of 38 patients (24%) had to change their positions. Among the 48 patients, 10 patients (21%) could not return to the same work, 7 of them found light duty and 3 of them had not been to work.

CONCLUSION

Although the functional results of surgical treatment of intra-articular distal humerus fractures are good, at the end of the treatment, especially heavy workers may have difficulties in returning to their former works.

An Overview of the Pathogenesis and Treatment of Elbow Osteoarthritis

The elbow joint could be associated with degenerative processes of primary and post-traumatic aetiology. Among these, osteoarthritis may also be secondary to repeated use as well as trauma. Pain, discomfort and progressive loss of functionality are common signs of this condition. The evaluation of elbow osteoarthritis should comprise an in-depth study to detect the primary cause of the illness and to facilitate the decision-making process regarding personalized treatment. Discordance between clinical manifestations and radiological findings is common. Conservative approaches may provide symptomatic relief in the early stages of disease for most patients. The goal of the treatment is to reduce pain and ensure an adequate range of motion and proper functioning of the joint while preserving the anatomical structure, to postpone elbow arthroplasty interventions for as long as possible. According to treatment guidelines, surgery should be considered depending on aetiology and severity, patient age, and functional demands. This narrative review aims to investigate the current literature regarding the pathogenesis and treatment of primary and post-traumatic arthritis of the elbow.

Results of a feasibility randomized controlled trial (RCT) of the Toolkit for Optimal Recovery (TOR): a live video program to prevent chronic pain in at-risk adults with orthopedic injuries

Background

Orthopedic injuries are the leading cause of hospital admissions in the USA, and many of these patients transition into chronic pain. Currently, there are no evidence-based interventions targeting prevention of chronic pain in patients with orthopedic injuries. We iteratively developed a four-session intervention "The Toolkit for Optimal Recovery" (TOR) which we plan to subsequently test for efficacy in a phase III hybrid efficacy-effectiveness multi-site clinical trial. In order to prevent methodological weaknesses in the subsequent trial, we conducted a feasibility pilot to evaluate the TOR delivered via secure live video versus usual care (UC) in patients with orthopedic injuries from an urban, level I trauma clinic, who screen in as at risk for chronic pain and disability. We tested the feasibility of recruitment, acceptability of screening, and randomization methods; acceptability of the intervention, treatment adherence, and treatment fidelity; satisfaction with the intervention; feasibility of the assessment process at all time points; acceptability of outcome measures for the definitive trial; and within-treatment effect sizes.

Methods

We aimed to recruit 50-60 participants, randomize, and retain them for ~ 4 months. Assessments were done electronically via REDCap at baseline, post-intervention (approximately 5 weeks after baseline), and 3 months later. We followed procedures we intend to implement in the full-scale hybrid efficacy-effectiveness trial.

Results

We recruited 54 participants and found that randomization and data collection procedures were generally acceptable. The majority of participants were white, educated, and employed. Warm hand-off referrals were more effective than research assistants directly approaching patients for participation without their providers' engagement. Feasibility of recruitment, acceptability of screening, and randomization were good. Satisfaction with the program, adherence to treatment sessions, and treatment fidelity were all high. There were no technical issues associated with the live video delivery of the TOR. There was minimal missing data and outcome measures were deemed appropriate. Effect sizes for improvement after participation in TOR were moderate to large. There were many lessons learned for future trials.

Conclusions

This study provided evidence of the feasibility of the planned hybrid efficacy-effectiveness trial design when implemented at our home institution. Establishing feasibility of the intervention and study procedures at other trauma centers with more diverse patient populations and different clinical practices is required before a multi-site phase III efficacy-effectiveness trial.

Trial registration

ClinicalTrials.gov ID: NCT03405610. Registered on January 28, 2018-retrospectively registered.

Validation of the Liverpool Elbow Score for evaluation of elbow stiffness

Background

The Liverpool Elbow Score (LES) has been widely used to assess the outcomes of total elbow replacement in various conditions. However, there have been no published validation studies on LES for patients with stiff elbows undergoing arthrolysis. The purpose of this study was to find out whether LES could be equally applied to evaluate joint function in patients with elbow stiffness.

Methods

A total of 63 patients with elbow stiffness were included in this retrospective validation study. The LES combines a nine-item patient-answered questionnaire (PAQ) and a six-item clinical assessment score (CAS), and can also be divided to evaluate two different parameters: elbow motion capacity (EMC) and elbow-related symptoms (ERS). Construct validity was assessed by correlating LES with previously validated scoring systems, and Spearman correlation coefficients (SCCs) were calculated. Effect size (ES) and standardized response mean (SRM) were calculated to determine responsiveness.

Results

There were no ceiling or floor effects in the target population. Good-to-excellent validity was determined based on total score (0.45–0.89), PAQ (0.42–0.88), CAS (0.35–0.60), EMC (0.46–0.86), and ERS (0.36–0.59). High responsiveness (ES/SRM) was observed in total score (2.80/2.24), PAQ (2.34/1.78), CAS (2.90/2.34), EMC (2.92/2.35), and ERS (0.55/0.52).

Conclusion

Our results suggest that the LES is a valid elbow-specific scoring system that can be used to evaluate joint function in patients with elbow stiffness, though some items included had some weakness either.

Retrospective Evaluation of Surgical Anatomical Repair of Distal Biceps Brachii Tendon Rupture Using Suture Anchor Fixation

BACKGROUND To date, no consensus has been reached regarding the preferred fixation method to use in the repair of distal biceps brachii tendon rupture. The aim of this study was to clinically and functionally (Mayo Elbow Performance Index, MEPI) assess the upper limb after surgical anatomic reinsertion of the distal biceps brachii tendon with the use of suture anchor fixation method with regard to postoperative time and limb dominance, and to assess postoperative complications. MATERIAL AND METHODS The sample comprised 18 males (age 52.09±8.89 years) after surgical anatomical distal biceps brachii reinsertion using suture anchor fixation. A comprehensive clinical and functional evaluation and pain assessment were performed. RESULTS In terms of postoperative complications, an isolated case of surgical site sensory disturbances was noted. Circumferences (p-value 0.21-1.00) and ROM (p-value 0.07-1.00) were similar in the operated and nonoperated limbs. The isometric torque (IT) values of muscles flexing and supinating the forearm were comparable in both limbs (p-value 0.14-0.95), but in patients with the operated dominant limb, the mean IT value was not higher than the value obtained in the nonoperated nondominant one. The MEPI indicated good and excellent results (80.00±15.00-90.00±8.66 points), but a detailed individual analysis showed that reported scores were not in line with objectively measured features. CONCLUSIONS The results of the comprehensive retrospective evaluation justify the clinical use of suture anchors fixation method in the surgical anatomical reinsertion of a ruptured distal biceps brachii tendon. The assessment of a patient should always report both subjective and objective measures.

The Influence of Psychological Factors on the Michigan Hand Questionnaire

Background: Psychosocial factors help account for the gap between impairment and disability. This study examines the relationship between the Michigan Hand Questionnaire (MHQ) and commonly used psychological measures in patients with upper extremity illness. Methods: A cohort of 135 new or follow-up patients presenting to an urban academic hospital-based hand surgeon were invited to complete a web-based version of the MHQ, Abbreviated Pain Catastrophizing Scale (PCS), and two Patient-Reported Outcomes Measurement Information System (PROMIS)-based questionnaires: Pain Interference and Depression. Bivariate and multivariable analyses measured the correlation of these psychological measures with MHQ. Results: Accounting for potential confounding factors in multivariable regression, upper extremity disability as rated by the MHQ was independently associated with PROMIS Depression, PROMIS Pain Interference, visit type, and working status. The model accounted for 37% of the variability in MHQ scores, with PROMIS Pain Interference having the most influence. Conclusion: Among the non-pathophysiological factors that contribute to patient-to-patient variation in MHQ scores, the measure of less effective coping strategies and symptoms of depression were most influential. Our data add to the evidence of the pivotal role of emotional health in upper extremity symptoms and limitations and the importance of psychosocial considerations in the care of hand illness.

Is Social Support Associated With Upper Extremity Disability?

BACKGROUND

Pain intensity and disability correlate with psychosocial factors such as depression and pain interference (the degree to which pain interferes with activities of daily living) as much or more than pathophysiology in upper extremity illness. However, other factors like emotional support (perception of being cared for and valued as a person), instrumental support (perception of availability of tangible assistance when needed), positive psychosocial impact (perception and focus on the positive side of a difficult situation, sometimes characterized as posttraumatic growth, benefit-finding, or meaning making), also might be associated with disability in patients with upper extremity orthopaedic illness. This is the first published study, to our knowledge, addressing the potential association of emotional support, instrumental support, and positive psychosocial illness impact with disability in patients with upper extremity illness.

QUESTIONS/PURPOSES

We asked: (1) Is there a correlation between the QuickDASH and the Patient-reported Outcomes Measurement Information System (PROMIS(®)) emotional support Computer Adaptive Testing (CAT)? (2) Is there a correlation between the QuickDASH and PROMIS(®) instrumental support CAT? (3) Is there a correlation between the QuickDASH and PROMIS(®) positive psychosocial illness impact CAT? (4) Among the PROMIS(®) measures of depression, emotional support, instrumental support, positive illness impact, and pain interference, which accounts for the most variance in QuickDASH scores?

METHODS

One hundred ninety-three patients with upper extremity illness (55% women; average age, 51 ± 18 years) of 213 approached (91% recruitment rate) completed the QuickDASH, and five different PROMIS(®) CATs: pain interference (the degree to which pain interferes with accomplishing one's goals), depression, emotional support, psychosocial illness impact, and instrumental support. We recruited patients from the practice of three surgeons in hand service of the department of orthopaedic surgery at a major urban university hospital.

RESULTS

Pearson Product Moment Correlations showed that emotional support (r = -0.18; p = 0.014) and instrumental support (r = -0.19; p = 0.008) were weakly and inversely associated with the QuickDASH), while positive psychosocial illness impact was moderately and inversely associated with the QuickDASH (r = -0.36; p < 0.001). In multivariable analyses, pain interference, but not the social support measures, was the only psychosocial factor associated with the QuickDASH and alone explained 66% of variance.

CONCLUSIONS

Emotional support, instrumental support and positive psychosocial illness impact are all individually associated with disability to a small degree, but pain interference (the degree to which pain interferes with accomplishing one's goals) has the strongest influence on magnitude of disability.

LEVEL OF EVIDENCE

Level 1, prognostic study.

Outcome after total elbow arthroplasty: a retrospective study of 167 procedures performed from 1981 to 2008

BACKGROUND

Total elbow arthroplasties (TEAs) are traditionally grouped into linked and unlinked design. The aim was to analyze the difference in clinical outcomes after TEA based on implant design and indication for surgery and to evaluate primary and revision TEAs.

METHODS

A total of 167 TEAs (126 primary and 41 revision TEAs) in 141 patients were evaluated with patient-reported outcome measure by the Oxford Elbow Score (OES) and clinically assessed with the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and standard radiographs.

RESULTS

The mean follow-up was 10.5 years for primary and 7.5 years for revision TEAs. There was no difference in OES or MEPS between linked and unlinked primary TEAs. The OES score in the social-psychological domain was significantly lower in TEAs performed due to fracture (67) compared with rheumatoid arthritis (81; P = .025). ROM in extension-flexion was 116° for primary linked TEAs compared with 110° for primary unlinked TEAs (P = .02). Revision TEAs were associated with a poorer outcome in OES, MEPS, and ROM compared with primary TEAs. Radiographic signs of loosening were seen in 15 primary and 7 revision TEAs at follow-up.

CONCLUSIONS

We found no clinically significant differences in outcomes after linked or unlinked TEAs. Patients with TEAs due to fracture had poorer social-psychological results than rheumatoid arthritis patients. The results after revision surgery were significantly inferior compared with primary procedures. The OES contributes to the evaluations of the outcome after TEA surgery with a nuanced picture of the patient's perception.

Does Disability Correlate With Impairment After Hand Injury?

BACKGROUND

Any loss or deviation in body function and structure is considered impairment, whereas limitations on activities are fundamental to the definition of disability. Although it seems intuitive that the two should be closely related, this might not be the case; there is some evidence that psychosocial factors are more important determinants of disability than are objective impairments. However, the degree to which this is the case has been incompletely explored.

QUESTIONS/PURPOSES

The purpose of this study was to determine if disability (as measured by the Disabilities of the Arm, Shoulder and Hand [DASH] and the Michigan Hand Questionnaire [MHQ]) and pain intensity correlate with impairment (as measured by the American Medical Association [AMA] impairment guide). Secondary study questions addressed the effect of pain intensity and symptom of depression on predicting disability.

METHODS

Impairment and disability were evaluated in a sample of 107 hand-injured patients a mean of 11 months after injury. Impairment rating was performed prospectively. From the patients who came for therapy, they were invited to fill out the questionnaire and evaluated for impairment rating. Response variables of DASH, MHQ, and visual analog scale pain intensity values were collected at the same setting. Other explanatory variables included demographic, injury-related, and psychological factors (symptoms of depression measured with the Beck Depression Inventory). Initial bivariate and multivariate analyses were performed to determine correlations of disability and pain to impairment rating and other exploratory variables.

RESULTS

Disability as measured by the DASH showed intermediate correlation with AMA impairment (r = 0 .38, beta = 0.36, p = 0.000). Together with gender, it accounted for only 22% of the variability in DASH scores. Similarly, MHQ score correlated with impairment rating (r = -0.24, beta = -0.23, p < 0.05). However, together with age, injured hand accounted for only 19% of the variability in MHQ scores. However, pain intensity did not correlate with impairment (r = -0.46, p > 0.05). Interestingly, pain intensity did correlate with the time passed from surgery but it was correlated with symptom of depression (r(2) = 0.10, beta = 0.33, p = 0.001).

CONCLUSIONS

The limited correlation between impairment and disability emphasizes the importance of factors other than pathophysiology in human illness behavior. These may include physical (pain, dominant injured hand) and conditional factors (time since surgery) or psychological factors such as depression and adapting; all mentioned can be considered as personal factors that may be different in each patient. So considering personal difference and any other condition except the impairment alone can help to better plan interventions and also diminish disability level.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Influence of Priming on Patient-Reported Outcome Measures: A Randomized Controlled Trial

BACKGROUND

Patient-reported outcome measures (PROMs) are influenced by psychosocial factors, but it is unknown whether we can influence PROM scores by modifying the mindset of the patient.

PURPOSE

We assessed whether priming affects scores on PROMs.

METHODS

In all, 168 patients with musculoskeletal illness participated in this double-blinded, randomized, controlled, parallel study between July 2014 and October 2014 in a level I trauma center. Inclusion criteria were patients aged 18 years or older with English fluency and literacy and the ability to provide informed consent. Priming was performed by means of the Pain Catastrophizing Scale (PCS). The patients were randomized (1:1:1) into 3 groups: intervention group I was negatively primed with the original PCS; intervention group II was positively primed with a positively phrased PCS group; and control group III was not primed. Assessments were performed using PROMs on the domain of physical function, depression, and pain. Bivariate and multivariable regression analyses were conducted.

RESULTS

The intervention and control groups were well balanced in demographic and condition-specific characteristics. The positive PCS was independently associated with higher PROM scores in the physical function domain (Patient-Reported Outcome Measurement Information System Upper Extremity Function: coefficient = 4.7, partial R(2) = 0.042; CI: 1.2-8.2; p < 0.010).

CONCLUSIONS

Patients primed with a positively phrased version of the PCS reported less functional disability as compared with patients who were either negatively primed or not primed at all. This suggests that by influencing the mindset, PROMs can be influenced, resulting in better outcome if positively primed.

LEVEL OF EVIDENCE

Level 1 therapeutic study.

TRIAL REGISTRATION

NCT02209259.

A Novel Quantitative Pain Assessment Instrument That Provides Means of Comparing Patient's Pain Magnitude With a Measurement of Their Pain Tolerance

Background

Traditional pain assessment instruments are subjective in nature. They are limited to subjective reporting of the presence and magnitude of pain. There is no means of validating their response or assessing their pain tolerance. The objective of this study was to determine the potential value of a novel addition to the traditional physical examination concerning a patient’s pain and more importantly their pain tolerance.

Methods

Extensive preliminary data were collected on 359 consecutive private practice knee patients referable the subject’s pain, including the magnitude, the most pain ever experienced, and their opinion of personal pain tolerance. The novel evaluation included physical testing of a series of small ball drops through a vertical tube from various fixed levels on the index finger and patella. The patient’s response to this impact testing provided quantitative information, from which a comparison was made to their pain opinion and also to that of other patients with similar demographics.

Results

Nine percent of the patients rated their pain tolerance below the midpoint on the visual analog scale. Seventy-one percent thought they were above the midpoint on the scale in regards to pain tolerance. There were discrepancies in both directions between the subject’s opinion on pain tolerance and their rating of their pain experience to the ball drop testing. Twenty-eight percent of the entire patient group rated themselves above 5 on tolerance, but experienced above the average discomfort compared to other subjects reporting on the finger impact testing.

Conclusions

This report introduces a novel method for collecting data concerning pain that can be subjected to quantification. The database included quantitative measures providing the opportunity to confirm, validate or refute the patient’s assertions concerning pain magnitude and tolerance. This method is best described as a patient pain profile. It has the potential to give both the patient and the physician quantified objective information rendering insight not otherwise available.

Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients

BACKGROUND

There is scant contemporary literature describing the outcomes of nonoperative management of distal humeral fractures. The aim of this study was to report the functional and radiographic outcomes after nonoperative management of distal humeral fractures.

METHODS

Between 2007 and 2013, 32 low-demand, medically unwell, or older patients with distal humeral fractures were treated nonoperatively. At the time of this study, 8 patients had died of unrelated causes, and 5 patients were lost to follow-up. The remaining 19 patients, with a mean age of 77 years, were available for a comprehensive assessment.

RESULTS

At a mean of 27 ± 14 months of follow-up, 68% (13 of 19) of patients reported good to excellent subjective outcomes. Outcomes in 2 patients were classified as poor, one of whom underwent total elbow arthroplasty as a result. Overall, the mean score on the Patient Rated Elbow Evaluation was 16 ± 23 and the Mayo Elbow Performance Index was 90 ± 11. When the injured was compared with the uninjured side, extension (22° ± 11° vs 8° ± 12°; P = .025) and flexion (128° ± 16° vs 142° ± 7°; P = .002) were significantly worse in the injured elbows. The fracture union rate was 81% (22 of 27) at a mean radiographic follow-up of 12 months.

CONCLUSIONS

Satisfactory outcomes were observed after the nonoperative management of selected distal humeral fractures in lower-demand, medically unwell, or older patients. Fracture union can be expected in most patients. In the uncommon instance when an unsatisfactory outcome occurs, successful salvage can be achieved with conversion to a total elbow arthroplasty.

Language barriers in Hispanic patients: relation to upper-extremity disability

BACKGROUND

Although upper-extremity disability has been shown to correlate highly with various psychosocial aspects of illness (e.g., self-efficacy, depression, kinesiophobia, and pain catastrophizing), the role of language in musculoskeletal health status is less certain. In an English-speaking outpatient hand surgery office setting, we sought to determine (1) whether a patient's primary native language (English or Spanish) is an independent predictor of upper-extremity disability and (2) whether there are any differences in the contribution of measures of psychological distress to disability between native English- and Spanish-speaking patients.

METHODS

A total of 122 patients (61 native English speakers and 61 Spanish speakers) presenting to an orthopaedic hand clinic completed sociodemographic information and three Patient-Reported Outcomes Measurement Information System (PROMIS)-based computerized adaptive testing questionnaires: PROMIS Pain Interference, PROMIS Depression, and PROMIS Upper-Extremity Physical Function. Bivariate and multivariable linear regression modeling were performed.

RESULTS

Spanish-speaking patients reported greater upper-extremity disability, pain interference, and symptoms of depression than English-speaking patients. After adjusting for sociodemographic covariates and measures of psychological distress using multivariable regression modeling, the patient's primary language was not retained as an independent predictor of disability. PROMIS Depression showed a medium correlation (r = -0.35; p < 0.001) with disability in English-speaking patients, while the correlation was large (r = -0.52; p < 0.001) in Spanish-speaking patients. PROMIS Pain Interference had a large correlation with disability in both patient cohorts (Spanish-speaking: r = -0.66; p < 0.001; English-speaking: r = -0.77; p < 0.001). The length of time since immigration to the USA did not correlate with disability among Spanish speakers.

CONCLUSION

Primary language has less influence on symptom intensity and magnitude of disability than psychological distress and ineffective coping strategies. Interventions to optimize mood and to reduce pain interference should be considered in patients of all nationalities.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A preliminary RCT of a mind body skills based intervention addressing mood and coping strategies in patients with acute orthopaedic trauma

OBJECTIVE

To test the acceptability and feasibility of a mind body skills-based intervention (RRCB) and estimate its preliminary effect in reducing disability and pain intensity as compared to standard care (SC) in patients with acute musculoskeletal trauma.

DESIGN

Randomised controlled trial.

SETTING

Level I trauma centre.

PATIENTS

Adult patients with acute fractures at risk for chronic pain and disability based on scores on two coping with pain measures who presented to an orthopedic trauma center and met inclusion and exclusion criteria.

INTERVENTION

Participants were randomied to either RRCB with SC or SC alone.

MAIN OUTCOME MEASUREMENT

Disability (short musculoskeletal functional assessment, SMFA) and pain (Numerical Analogue Scale).

SECONDARY OUTCOME MEASURES

coping strategies (Pain Catastrophizing Scale, PCS and Pain Anxiety Scale, PAS) and mood (CESD Depression and PTSD checklist).

RESULTS

Among the 50 patients consented, two did not complete the initial assessment. Of these, the first four received the intervention as part of an open pilot and the next 44 were randomised (24 RRCBT and 20 UC) and completed initial assessment. We combined the patients who received RRCB into one group, N=28. Of the entire sample, 34 completed time two assessments (24 RRCBT and 10 SC). The RRCB proved to be feasible and accepted (86% retention, 28 out of 24 completers). Analyses of covariance ANCOVA showed a significant (p<05) improvement and large effect sizes for all time two main study variables (.2-.5) except pain with activity where the effect size was medium (.08). Improvement for pain at rest was not significantly higher in the RRCB as compared to the control, for a small effect size (.03).

CONCLUSION

The RRCB is feasible, acceptable and potentially efficacious.

LEVEL OF EVIDENCE

Level 1 prognostic.

The Boyd-McLeod procedure for tennis elbow: mid- to long-term results

BACKGROUND

Tennis elbow is a common condition that usually responds to conservative measures. In refractory cases, surgical intervention is indicated. A plethora of surgical techniques have been described. We report the mid- to long-term outcomes of the Boyd-McLeod procedure for refractory tennis elbow.

METHODS

A retrospective analysis and current review of patients that had undergone the Boyd-McLeod procedure over a 12-year period was undertaken. Demographics, time to discharge, length of follow-up and outcome scores were collected.

RESULTS

Seventy patients underwent surgery. Mean time to discharge was 15.35 weeks, with 88% successful outcomes. Fifty-four patients were available for current follow-up at mean of 5.52 years (range 1.17 years to 11.49 years). Range of motion in all patients was unchanged. There were no revision procedures. Mean (SD) Mayo Elbow Performance Score was 90.85 (13.11), with 75.5% returning a good or excellent score and 24.5% a fair outcome. The mean (SD) Oxford Elbow Score was 44.04 (6.92); mean (SD) pain score was 89.5 (17.58); mean (SD) function score was 95.34 (9.59) and mean (SD) socio-psychological score was 91.50 (17.01). Overall, 83% of patients had an Oxford Elbow Score of 43 or greater, suggesting excellent outcome.

CONCLUSIONS

We show that the Boyd-McLeod procedure is an excellent option over both the short- and long-term for refractory tennis elbow.

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

Cognitive flexibility - the ability to restructure one's knowledge, incorporate new facts, widen perspective, and adapt to the demands of new and unexpected conditions - can help one adapt to illness. The aim of this study was to assess the relationship between cognitive flexibility and hand and upper extremity specific disability in patients presenting to a hand surgeon. Secondarily, we determined predictors of cognitive flexibility and pain. Eighty-nine consecutive outpatients completed the Cognitive flexibility questionnaire (CFS), Short Health Anxiety Inventory-5 (SHAI-5), Pain Self-Efficacy Questionnaire (PSEQ), Disabilities of Arm, Shoulder and Hand, short form (QuickDASH), and Patient Health Questionnaire for Depression-2 (PHQ-2) in a cross-sectional study. CFS did not correlate with disability or pain intensity. Disability correlated with PSEQ (r = -0.66, p < 0.01), PHQ-2 (r = 0.38, p = <0.01), and SHAI-5 (r = 0.33, p < 0.01). Pain intensity correlated with PSEQ (r = -0.51 p < 0.01) and PHQ-2 (r = 0.41 p < 0.01). There was a small correlation between the CFS and PSEQ (r = 0.25, p = 0.02). The best multivariable models for QuickDASH and pain intensity included PSEQ and PHQ and explained 35 % and 28 % of the variability respectively. Upper extremity specific disability and pain intensity are limited more by self-efficacy than cognitive flexibility. Interventions to improve self-efficacy might help patients with upper extremity illness.

Long-term outcome of displaced, transverse, noncomminuted olecranon fractures

BACKGROUND

Operative treatment of a displaced, transverse, noncomminuted fracture of the olecranon is associated with good to excellent elbow function in retrospective short-term followup studies. However, to our knowledge, no studies have evaluated objective and subjective outcomes using standardized outcome instruments (ie, DASH and Mayo Elbow Performance Index [MEPI]) to quantify long-term outcome of these specific fractures.

QUESTIONS/PURPOSES

We evaluated (1) factors associated with disability, as measured with the DASH questionnaire; (2) factors associated with ulnohumeral motion; (3) factors associated with pain intensity; and (4) general descriptive findings for posttraumatic arthrosis, MEPI, ulnar neuropathy symptoms, and return to work between 10 and 32 years after open reduction and internal fixation (ORIF) of a transverse, noncomminuted fracture of the olecranon.

METHODS

Between 1977 and 1997, we performed ORIFs of transverse, noncomminuted olecranon fractures in 109 patients, of whom 35 had died, 14 had incomplete data in our registry, and 19 were lost to followup or declined participation, leaving 41 patients available for followup at a minimum of 10 years after surgery. During that time, our general indication for performing ORIF was greater than 2 mm displacement. The average age of these patients at the time of injury was 35 years (range, 18-73 years). Patient-reported outcome was quantified using the DASH questionnaire, and physician-based outcome was evaluated using the MEPI. To identify factors associated with disability (DASH), impairment (MEPI), ulnohumeral motion, and pain, we examined demographic and clinical data in bivariate analyses, and subsequently significant factors in multivariate analysis to identify independent predictors of outcome.

RESULTS

The sole factor associated with higher DASH scores in multivariable analysis was age at surgery, explaining 20% of the variability, with younger patients performing better. The mean arc of elbow flexion was 142° (range, 110°-160°), and the variation was associated with arthrosis alone (ie, a greater arc of motion was associated with a lesser grade of arthrosis according to the system of Broberg and Morrey). Pain was uncommon and generally was correlated with adverse events.

CONCLUSIONS

The good results of operative fixation (tension-band wiring) of a transverse, displaced olecranon fracture are durable with time. Patient-reported outcomes are excellent in the majority of patients. Residual patient-rated disability does not correlate with arthrosis or loss of extension.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The correlation of phrases and feelings with disability

BACKGROUND

Patient expressions reflect disability and psychological factors. The aim of this study was to list common phrases and feelings in hand surgery practice and to prospectively study the correlation of these phrases and to correlate them with possible associated feelings and disability.

METHODS

Eighty-three patients completed the short version of the disabilities of arm, shoulder and hand (QuickDASH) questionnaire to measure disability, the pain self-efficacy questionnaire (PSEQ) to study coping, and a pain scale. The patients also completed the phrases and feelings questionnaire, which list verbal expressions patients often use. Pearson's correlation was used to test the correlation of continuous variables, and independent t test and one-way ANOVA were used for categorical variables. All variables with p < 0.08 were inserted in a multivariable regression.

RESULTS

There was a large correlation between the individual phrases and feelings questions with PSEQ and QuickDASH. The best model for the combined phrases questionnaire included pain, PSEQ, smoking, and other pain conditions. The best model for the combination of all the feelings questions included PSEQ, pain, and marital status. The best model for QuickDASH included phrases, PSEQ, prior treatment, and working status, with phrases being the strongest factor.

CONCLUSIONS

Patients use specific phrases that indicate the magnitude of their disability and the effectiveness of their coping strategies. Providers should respond to these phrases by empathetically acknowledging these aspects of the human illness experience.

Abbreviated psychologic questionnaires are valid in patients with hand conditions

BACKGROUND

The Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) can help hand surgeons identify opportunities for psychologic support, but they are time consuming. If easier-to-use tools were available and valid, they might be widely adopted.

QUESTIONS/PURPOSES

We tested the validity of shorter versions of the PCS and SHAI, the PCS-4 and the SHAI-5, by assessing: (1) the difference in mean scaled scores of the short and long questionnaires; (2) floor and ceiling effects between the short and long questionnaires; (3) correlation between the short questionnaires and the outcome measures (an indication of construct validity); and (4) variability in disability and pain, between the short and long questionnaires.

METHODS

One hundred sixty-four new or followup adult patients in one hand surgery clinic completed the SHAI-18, SHAI-5, PCS-13, PCS-4, Patient Health Questionnaire (PHQ)-9, PHQ-2, DASH, and QuickDASH questionnaires, and an ordinal pain scale, as part of a prospective cross-sectional study. Mean scores for the short and long questionnaires were compared with paired t-tests. Floor and ceiling effects were calculated. Pearson's correlation was used to assess the correlation between the short and long questionnaires and with outcome measures. Regression analyses were performed to find predictors of pain and disability.

RESULTS

There were small, but significant differences between the mean scores for the DASH and QuickDASH (QuickDASH higher), SHAI-18 and SHAI-5 (SHAI-18 higher), and PCS-13 and PCS-4 (PCS-4 higher), but not the PHQ-9 and PHQ-2. Floor effects ranged between 0% and 65% and ceiling effects between 0% and 3%. There were greater floor effects for the PHQ-2 than for the PHQ-9, but floor and ceiling effects were otherwise comparable for the other short and long questionnaires. All questionnaires showed convergent and divergent validity and criterion validity was shown in multivariable analyses.

CONCLUSIONS

Content validity, construct convergent validity, and criterion validity were established for the short versions of the PCS and SHAI. Using shorter forms creates small differences in mean values that we believe are unlikely to affect study results and are more efficient and advantageous because of the decreased responder burden.

Isometric strength, range of motion, and impairment before and after total and reverse shoulder arthroplasty

BACKGROUND

Medicare Part A provides similar resources for coverage of inpatient hospitalization costs for patients treated with total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). This is based on an assumption that TSA and RSA are used to treat similar patient populations with comparable disease severity. However, no objective clinical information is available to support this resource allocation. The purpose of this study is to quantify the disease severity and subsequent improvement from primary TSA, primary RSA, and revision arthroplasty (TSA and RSA).

METHODS

From March 2004 through May 2006, 174 shoulders (87 primary TSA, 55 primary RSA, and 32 revision cases) were prospectively studied using Biodex (Biodex Medical Systems, Shirley, NY, USA) isometric strength and standardized video range of motion measurements performed by an independent third-party observer at 1 week before surgery and at an average of 49 months (range, 32-69 months) postoperatively. Patient impairment ratings were calculated using the Florida Impairment Guidelines.

RESULTS

Primary TSA had the lowest average preoperative impairment (21%), and revision arthroplasty had the highest (28%). All patients demonstrated improvement in the parameters tested. At an average 49 months, all 3 groups demonstrated a similar reduction in impairment ratings (TSA: 21% to 10%; RSA: 25% to 15%; revision arthroplasties: 28% to 20%).

CONCLUSION

There are distinct differences in preoperative disease severity among patients undergoing primary TSA, primary RSA, and revision arthroplasty. Greater impairment is evident in patients undergoing a revision arthroplasty. However, all groups may be expected to achieve improvements and maintain these improvements 4 years postoperatively.

Measurement scales in clinical research of the upper extremity, part 2: outcome measures in studies of the hand/wrist and shoulder/elbow

Part 1 of this article outlined the basic characteristics of useful clinical measurement instruments and described scales used to measure general health, pain, and patient satisfaction. Part 2 describes the features of some of the scales most commonly used in clinical research in the hand, wrist, elbow, and shoulder.

The influence of job satisfaction, burnout, pain, and worker's compensation status on disability after finger injuries

PURPOSE

Motivation, job satisfaction, burnout, and secondary gain are factors that can influence return to work and disability after orthopedic injuries. The current study evaluated the separate effects of job satisfaction, burnout, and secondary gain on arm-specific disability after a finger injury.

METHODS

Ninety-three employed patients with finger injuries were enrolled in this prospective study, and 51 completed the follow-up. Burnout (measured with Shirom-Melamed's Burnout Measure), job satisfaction (measured with the Job Descriptive Index questionnaire), and demographics were assessed at the initial visit. After 6 months, arm-specific disability was measured with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and general health status was measured with the Short Form-36 (SF-36) survey, mental component summary (MCS) and physical component summary (PCS).

RESULTS

In the 51 patients with complete follow-up, the mean DASH score was 12, the mean SF-36 PCS was 48, the mean SF-36 MCS was 49, and the mean pain rating was 2.1. In multivariable analysis, pain and worker's compensation status explained 52% of the variability in DASH scores (pain alone accounted for 49%); pain accounted for 14% of the variability in SF-36 PCS scores; and worker's compensation accounted for 11% of the variation in the SF-36 MCS scores.

CONCLUSIONS

The majority of variation in the SF-36 PCS and MCS scores remained unaccounted for by the models, but pain and worker's compensation were more important than job burnout or job satisfaction. Pain and worker's compensation were also significant predictors of the DASH.

CLINICAL RELEVANCE

Worker's compensation and pain were more important than job satisfaction and burnout in explaining variations in arm-specific disability in patients with finger injuries.

Upper extremity-specific measures of disability and outcomes in orthopaedic surgery

Outcome measures may consist of simple questions or they may be more complex instruments that evaluate multiple interrelated domains that influence patient function. Outcome measures should be relevant to patients, easy to use, reliable, valid, and responsive to clinical changes. The Disabilities of the Arm, Shoulder and Hand score can be used to measure disability for any region of the upper limb. Joint and disease-specific outcome measures have been developed for the shoulder, the elbow, and the wrist and hand. Many of these measures would benefit from further research into their validity, reliability, and optimal applicability.

The reliability, validity and responsiveness of the Dutch version of the Oxford elbow score

Background

The Oxford elbow score (OES) is an English questionnaire that measures the patients' subjective experience of elbow surgery. The OES comprises three domains: elbow function, pain, and social-psychological effects. This questionnaire can be completed by the patient and used as an outcome measure after elbow surgery. The aim of this study was to develop and evaluate the Dutch version of the translated OES for reliability, validity and responsiveness with respect to patients after elbow trauma and surgery.

Methods

The 12 items of the English-language OES were translated into Dutch and then back-translated; the back-translated questionnaire was then compared to the original English version. The OES Dutch version was completed by 69 patients (group A), 60 of whom had an elbow luxation, four an elbow fracture and five an epicondylitis. QuickDASH, the visual analogue pain scale (VAS) and the Mayo Elbow Performance Index (MEPI) were also completed to examine the convergent validity of the OES in group A. To calculate the test-retest reliability and responsiveness of the OES, this questionnaire was completed three times by 43 different patients (group B). An average of 52 days elapsed between therapy and the administration of the third OES (SD = 24.1).

Results

The Cronbach's α coefficients for the function, pain and social-psychological domains were 0.90, 0.87 and 0.90, respectively. The intra-class correlation coefficients for the domains were 0.87 for function, 0.89 for pain and 0.87 for social-psychological. The standardised response means for the domains were 0.69, 0.46 and 0.60, respectively, and the minimal detectable changes were 27.6, 21.7 and 24.0, respectively. The convergent validity for the function, pain and social-psychological domains, which were measured as the Spearman's correlation of the OES domains with the MEPI, were 0.68, 0.77 and 0.77, respectively. The Spearman's correlations of the OES domains with QuickDASH were -0.43, -0.44 and -0.47, respectively, and the Spearman's correlations with the VAS were -0.33, -0.38 and -0.42, respectively.

Conclusions

The Dutch OES is a reliable and valid 12-item questionnaire that can be completed within several minutes by patients with elbow injuries. This Dutch questionnaire was useful as an outcome measure in patients with elbow trauma.

The American Shoulder and Elbow Surgeons Elbow Questionnaire: cross-cultural adaptation into German and evaluation of its psychometric properties

The purpose of this clinical measurement (longitudinal) study was to cross-culturally adapt the American Shoulder and Elbow Surgeons standardized elbow assessment questionnaire (pASES-e) into German (pASES-eG) and evaluate its reliability and validity. Cross-cultural adaptation of the pASES-e was performed according to international guidelines. Seventy-five patients who had undergone elbow arthroplasty, on average of 11 years previously, were assessed using the pASES-eG, the German version of the Patient-Rated Elbow Evaluation (PREE-G), the Short Form-36 (SF-36), the Disabilities of Arm, Shoulder and Hand (DASH), and the clinical ASES-e to assess the construct validity of the pASES-eG. Its retest reliability was examined on 55-second assessments completed within two weeks. For reliability, the intraclass correlation coefficient was 0.93 for the pASES-eG total score. Its internal consistency was 0.90 (Cronbach's alpha). The pASES-eG total score correlated excellently with the PREE-G (0.92), well with the DASH (0.73), moderate with the physical component summary (0.62), and not with the mental component summary scores of the SF-36 (0.02). The pASES-eG correlated moderately with certain clinical findings (clinical ASES-e) (0.40-0.63). The pASES-eG represents a valid and reliable instrument for evaluating self-rated outcome in German-speaking patients with elbow pathology.

Relationships among pain disability, pain intensity, illness intrusiveness, and upper extremity disability in patients with traumatic peripheral nerve injury

PURPOSE

In patients with a peripheral nerve injury, a simple conceptualization assumes that pain disability is determined by pain intensity. This study evaluated the relationships among pain intensity, illness intrusiveness, and pain disability.

METHODS

After we obtained ethics board approval, we enrolled English-speaking adult patients who had experienced an upper extremity peripheral nerve injury 0.5 to 15 years previously. Patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH), Illness Intrusiveness Scale, Pain Disability Index, and McGill Pain questionnaires. We used multivariate linear regression to evaluate the variables that predicted pain disability.

RESULTS

There were 124 patients (41 women, 83 men; mean ± SD, 41 ± 16 y of age). The median time since injury was 14 months (range, 6-145 months), and there were 43 brachial plexus nerve injuries. Mean ± SD scores were: pain disability, 29 ± 18; illness intrusiveness, 40 ± 18; DASH, 45 ± 22; and pain intensity, 4.6 ± 3.0. The pain disability, DASH, and illness intrusiveness scores were significantly higher in patients with brachial plexus injuries than in those with distal nerve injuries (p<.05). There was strong correlation between pain disability and DASH (r = 0.764, p<.001) and illness intrusiveness (r = 0.738, p<.001) and a weaker correlation with pain intensity (r = 0.549, p<.001). The final regression model predicting pain disability scores explained 70% of the variance with these predictors: DASH (β = 0.452, p<.001), illness intrusiveness (β = 0.372, p<.001), and pain intensity (β = 0.143, p=.018).

CONCLUSIONS

Pain disability was substantial after nerve injury, and pain intensity explained the least variance among the model variables. Pain intensity should be considered only one component of pain, and the impact of pain in the context of disability should be considered in patients with chronic nerve injury.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Neuropathic pain in patients with upper-extremity nerve injury

PURPOSE

The purpose of this review was to present an analysis of the literature of the outcome studies reported in patients following traumatic upper-extremity (UE) nerve injuries (excluding amputation), to assess the presence of an association between neuropathic pain and outcome in patients following traumatic UE nerve injuries, and to provide recommendations for inclusion of more comprehensive outcome measures by clinicians who treat these patients.

SUMMARY OF KEY POINTS

A Medline and CINAHL literature search retrieved 48 articles. This review identified very few studies of patients with peripheral nerve injury that reported neuropathic pain. When pain was reported, visual analogue or numeric rating scales were most frequently used; standardized questionnaires measuring pain or psychosocial function were rarely administered. Recent evidence shows substantial long-term disability and pain in patients following peripheral nerve injury.

RECOMMENDATION

To better understand neuropathic pain in patients following peripheral nerve injury, future outcome studies should include valid, reliable measures of physical impairment, pain, disability, health-related quality of life, and psychosocial functioning.

Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates

HYPOTHESIS

Several studies have shown good results with internal fixation of distal humeral fractures; however, few have focused specifically on anatomic parallel plate fixation using the same implant and postoperative regimen. The purpose of this study was to determine the functional outcome after open reduction and internal fixation of these complex fractures using parallel precontoured anatomic plates.

MATERIALS AND METHODS

This was a retrospective single-surgeon series involving 16 patients (12 women, 4 men) treated with a double-column parallel plating technique. Clinical assessment included the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand Score (DASH). Mean age was 43 years (range, 20-78 years). Average follow-up was 35 months. Four fractures were AO type A and 12 were AO type C.

RESULTS

Union was achieved in all patients. There was no superficial or deep infection or hardware failure. Two patients required removal of plates for pain and prominence but not all screws could be completely removed. The mean flexion was 132 degrees and extension was 29 degrees . The mean DASH score was 46.1. Grip strength was 56% of the uninjured side. Mean flexion and extension force was 72% and 70%, respectively, of the uninjured elbow. The mean MEPS score was 72.3.

DISCUSSION

Anatomically precontoured parallel plates are effective in achieving bony union with low implant failure with acceptable functional outcomes. However, screw extraction can be difficult when the implant is removed.

Complex and unstable simple elbow dislocations: a review and quantitative analysis of individual patient data

Objective:

The primary objective of this review of the literature with quantitative analysis of individual patient data was to identify the results of available treatments for complex elbow dislocations and unstable simple elbow dislocations. The secondary objective was to compare the results of patients with complex elbow dislocations and unstable elbow joints after repositioning of simple elbow dislocations, which were treated with an external fixator versus without an external fixator.

Search Strategy:

Electronic databases MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials.

Selection Criteria:

Studies were eligible for inclusion if they included individual patient data of patients with complex elbow dislocations and unstable simple elbow dislocations.

Data Analysis:

The different outcome measures (MEPI, Broberg and Morrey, ASES, DASH, ROM, arthritis grading) are presented with mean and confidence intervals.

Main Results:

The outcome measures show an acceptable range of motion with good functional scores of the different questionnaires and a low mean arthritis score. Thus, treatment of complex elbow dislocations with ORIF led to a moderate to good result. Treatment of unstable simple elbow dislocations with repair of the collateral ligaments with or without the combination of an external fixator is also a good option.

The physician-rated (MEPI, Broberg and Morrey), patient-rated (DASH) and physician- and patient-rated (ASES) questionnaires showed good intercorrelations.

Arthritis classification by x-ray is only fairly correlated with range of motion.

Elbow dislocations are mainly on the non-dominant side.

Correlation of DASH and QuickDASH with measures of psychological distress

PURPOSE

In an attempt to shorten the questionnaires given to patients in both clinical and research settings, we studied whether the correlation of commonly used psychological measures was comparable for the standard Disabilities of the Arm, Shoulder, and Hand (DASH) and the shorter QuickDASH questionnaires.

METHODS

A cohort of 839 patients with carpal tunnel syndrome, trigger finger, de Quervain's disease, trapeziometacarpal arthrosis, lateral epicondylosis, or a distal radius fracture 2 weeks after surgery, who completed the DASH and 1 or more measures of psychological distress, was created from 10 databases from previously implemented studies. Correlations of the DASH and the QuickDASH with several measures of psychological factors (Center for Epidemiologic Studies Depression Scale [CES-D], Pain Catastrophizing Scale [PCS], and Pain Anxiety Symptoms Scale [PASS-40]) were calculated in both univariate and multivariable analyses.

RESULTS

There was a large correlation between the DASH and QuickDASH (r = 0.79; p < .001). QuickDASH scores were significantly higher than DASH scores (p < .001). Correlations of the CES-D, PCS, and PASS-40 with the DASH and QuickDASH ranged from small to medium (range, 0.21-0.31; p < .001). There were no significant differences between correlations of the DASH and the QuickDASH with the psychological factors in the cohort including all patients, nor in subgroups according to diagnosis, gender, and limb dominance.

CONCLUSIONS

The correlations of the DASH and QuickDASH with the CES-D, PCS, and PASS-40 were comparable. Our analysis suggests that a shorter and therefore potentially more practical measure of arm-specific disability can be used in studies that evaluate psychosocial aspects of illness behavior.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

A survey regarding physician recommendations regarding return to work

PURPOSE

Returning patients to work may be influenced by subjective factors and physician bias. The purpose of this study was to determine whether factors such as complaints of pain and patient motivation influence physicians' recommendations regarding return to work or activity.

METHODS

One hundred twenty-five members of the American Society for Surgery of the Hand completed an online survey describing a 25-year-old patient with surgically treated diaphyseal fractures of the radius and ulna. Physicians were asked whether the patient could be returned to work in 4 distinct scenarios varying with occupation, time since injury, radiographic union, patient motivation, and pain.

RESULTS

Logistic regression analysis demonstrated that all 5 predictor variables were highly significant predictors of return to work. Pain and diminished motivation were associated with a significantly lower probability of return to work.

CONCLUSIONS

Although in the scenario depicted, objective factors such as radiographic union and job demands are the major determinants of physician clearance to return to work, physicians are also influenced by patient motivation and complaints of pain.

Integrating patient values into evidence-based practice: effective communication for shared decision-making

Increasing data suggest that the traditional clinician-centered or disease-focused, biomedical approach to illness is less effective than a biopsychosocial, evidence-based, patient-centered approach to illness, particularly for chronic pain conditions. This article distinguishes patient-centered care from more traditional and outdated biomedical decision-making models; illustrates the complexity of illness behavior with a patient example; delves into the communication issues raised by this complexity, thereby demonstrating how best evidence can sometimes run counter to biases and intuition; provides a summary of evidence that patient-centered care positively affects outcomes; and explores how the shared decision-making approach along with cultivation of good communication skills can facilitate evidence-based practice.

Patient-reported outcome after peripheral nerve injury

PURPOSE

This study evaluated patient-reported outcome and the factors associated with disability after an upper extremity nerve injury. We hypothesized that patients at least 6 months after injury would report considerable disability and that pain would be the strongest predictor of the Disabilities of the Arm, Shoulder, and Hand (DASH) score.

METHODS

After research ethics board approval, the medical charts of patients with these inclusion criteria were reviewed: adults; presenting to a nerve surgeon; 6 months or greater after nerve injury. Patients completed the DASH questionnaire and the Short Form-36 (SF-36) as a routine part of the initial evaluation. These data were reviewed retrospectively to determine predictors of the DASH score.

RESULTS

There were 84 patients (mean age, 39 years; SD, 14 years) with brachial plexus (n=27) and peripheral nerve (n=57) injuries. The mean time after injury was 38 months (SD, 47). For all SF-36 domains, the mean values of the nerve-injured patients were significantly lower than the normative data, indicating a lower health status. The mean DASH score was 52 (SD, 22) of 100. Significantly more disability was associated with more SF-36 bodily pain and with brachial plexus injuries. In the final regression model, SF-36 bodily pain, age, and nerve injured were significant predictors of the DASH score. SF-36 bodily pain accounted for 35% of the variance.

CONCLUSIONS

Substantial long-term disability (high DASH scores) was found in patients after nerve injury that was predicted by higher pain, older age, and brachial plexus injury. Further investigation of this pain and the associated factors may provide the opportunity for improved health-related quality of life.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Influence of psychological factors on grip strength

PURPOSE

Grip strength is widely used to assess upper-extremity function. Although grip strength is a quantitative measure of function, grip strength is a reflection of both physical impairment as well as subjective, psychological factors. We investigated the determinants of grip strength with the hypothesis that psychological factors are associated with diminished grip strength.

METHODS

One hundred thirty-four patients with an isolated, discrete upper-extremity condition had grip strength measurements, and, as part of one of several prospective clinical studies, during the same visit they completed 2 or more of the following surveys: the Center for Epidemiologic Studies-Depression (CES-D) scale, Pain Anxiety Symptoms Scale, and Pain Catastrophizing Scale. Univariate and multivariable statistical analysis sought determinants of absolute grip strength and grip strength as a percentage of the opposite, uninvolved limb.

RESULTS

Determinants of absolute grip strength included gender and grip strength of the uninvolved limb. The association between CES-D score and absolute grip strength was near significant but very weak. Multivariable regression analysis produced a best-fit model that retained grip strength of the uninvolved limb and CES-D scores. When grip strength of the involved limb was evaluated as a percentage of grip strength of the uninvolved limb, CES-D score was a weak but significant predictor, and patients recovering from a fracture of the distal radius had weaker grip strength than did patients with nontraumatic conditions.

CONCLUSIONS

Depression scores were minimally associated with diminished grip strength. Psychological factors appear to affect disability (patient-reported health status) more than they affect performance-based measures of function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger

PURPOSE

This study was designed to test the null hypothesis that there is no difference in resolution of triggering 3 months after injection with either a soluble (dexamethasone) or insoluble (triamcinolone) corticosteroid for idiopathic trigger finger.

METHODS

Eighty-four patients were enrolled in a prospective randomized controlled trial comparing dexamethasone and triamcinolone injection for idiopathic trigger finger. Sixty-seven patients completed the 6-week follow-up (35 triamcinolone arm, 32 dexamethasone arm), and 72 patients completed the 3-month follow-up (41 triamcinolone arm, 31 dexamethasone arm). Outcome measures included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, trigger finger grading according to Quinnell, and satisfaction on a visual analog scale. To preserve autonomy, patients were permitted additional injections and operative treatment at any time. Twenty-five patients requested a second injection (10 triamcinolone arm, 15 dexamethasone arm), and 21 elected operative treatment (10 triamcinolone arm, 11 dexamethasone arm) during the study period. The analysis was according to intention to treat principles.

RESULTS

Six weeks after injection, absence of triggering was documented in 22 of 35 patients in the triamcinolone cohort and in 12 of 32 patients in the dexamethasone cohort. The rates 3 months after injection were 27 of 41 in the triamcinolone cohort and 22 of 31 in the dexamethasone cohort. The triamcinolone cohort had significantly better satisfaction and Quinnell grades than did the dexamethasone cohort at the 6-week follow-up but not at the 3-month follow-up. There were no significant differences between Disabilities of the Arm, Shoulder, and Hand scores at the 6-week follow-up and the 3-month follow-up. After the close of the study, there were 8 recurrences among patients with documented absence of triggering in the triamcinolone cohort and 1 in the dexamethasone cohort.

CONCLUSIONS

Although there were no differences 3 months after injection, our data suggest that triamcinolone may have a more rapid but ultimately less durable effect on idiopathic trigger finger than does dexamethasone.

Predictors of wrist function and health status after operative treatment of fractures of the distal radius

PURPOSE

To identify the most important determinants of physician-based and patient-based scoring systems for the wrist and upper extremity after operative treatment of a fracture of the distal radius, with the hypothesis that pain is the strongest determinant of both types of scores.

METHODS

Eighty-four patients were evaluated a minimum of 6 months after operative fixation of an unstable distal radius fracture using 2 physician-based evaluation instruments (the Mayo Wrist Score and the Gartland and Werley Score) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder, and Hand; DASH). Multivariate analysis of variance and multiple linear regression modeling were used to identify the degree to which various factors affect variability in the scores derived with these measures.

RESULTS

The physician-based scoring systems showed moderate correlation with each other and with DASH scores. The results of multiple linear regression modeling were as follows (percent variability accounted for by the best fit model/model with top factor alone): Mayo: 54% grip and flexion arc/47% grip alone; Gartland and Werley: 70% pain, flexion arc, radiocarpal arthritis, and duration of follow-up/53% pain alone; DASH: 71% pain, forearm arc, and type of fracture/65% pain alone.

CONCLUSIONS

At early follow-up, pain dominates the patient's perception of function after recovery from an operatively treated distal radius fracture as measured by the DASH score and the physician-based rating according to the system of Gartland and Werley. The Mayo Wrist Score is determined primarily by grip strength rather than pain. Because perception of pain and strength of grip have been shown to be influenced by psychosocial factors in some individuals, both patient-based and physician-based measures of wrist function may be vulnerable to illness behavior.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Rating systems for evaluation of the elbow

INTRODUCTION

Many scoring systems have been used for elbow disorders. However, only few of these have been validated, and many assess only few aspects of elbow function.

METHODS

A literature search was performed using the keyword 'elbow' in combination with 'scoring system', 'outcome assessment', 'elbow disorder' and 'clinical evaluation'.

RESULTS

Eighteen scoring systems are currently available for the evaluation of elbow disorders. Each of them evaluates the elbow performance using specific variables, including both objective and subjective criteria. All these scoring systems are presented.

DISCUSSION

Although many scoring systems have been used to evaluate elbow function, we are still far from a single outcome evaluation system which is reliable, valid and sensitive to clinically relevant changes, takes into account both patients' and physicians' perspective and is short and practical to use.

CONCLUSION

Further studies are required to evaluate the reliability, validity and sensitivity of the elbow scoring systems used in the common clinical practice.

Examination of the elbow: linking diagnosis, prognosis, and outcomes as a framework for maximizing therapy interventions

A conceptual framework for examination of the elbow by the therapist is presented. The role of history taking including patient life-style factors, comorbidities and goals; pain assessment; utility of provocative maneuvers and range of motion analysis are presented. Assessment of strength using hand-held dynamometry is described. Pain and disability measures relevant to patients with elbow pathology are discussed and one patient self report instruments is appended (the Patient-rated Elbow Evaluation). The psychometrics properties of tests for the elbow, when available, are reviewed. A template for recording an elbow examination is provided.