Self-reported upper extremity health status correlates with depression

The Psychological Impact of Hand Injuries Among Foreign Workers in Singapore

INTRODUCTION

 Foreign workers comprise a significant portion of Singapore's workforce. They face multiple challenges when working there. A hand injury may add to these stressors, causing profound psychological and social impact. There are few studies in the literature that have analyzed this effect. The primary objective of this study, the first of its kind in Singapore, is to investigate the psychological impact and functional outcomes of hand injuries among foreign workers. By assessing the prevalence of psychological conditions such as stress, anxiety, and depression, along with measuring functional impairment using validated tools, this study aims to provide insights into the psycho-social challenges faced by this vulnerable population.

METHODS

 A single-encounter interview was conducted for eligible patients. Psychological impact was measured using the DASS-21, symptom severity and function with the QuickDASH, and pain with the VAS. Injury-specific and demographic data were also collected. The Mann-Whitney U test and the Chi-Squared test were applied for non-parametric variables and categorical data, respectively. The adjusted p-value was <0.05.

RESULTS

Eighty foreign workers were recruited. The mean age was 33 years, and the median age was 31.5 years (28.2 to 37.0). The majority were male (97.5%), married (60%), and had a salary of less than SGD1500 (USD1077) per month (81.3%). The most common mechanism of injury was penetrating (60%, n=48). Stress, anxiety, and depression were positively associated with limitations in daily function. Multivariate analysis found that limitations in daily function were independently associated with stress, anxiety, and depression, regardless of hand dominance.  Conclusion: This study has shown a significant psychological and social impact of hand injuries among foreign workers in Singapore. There is potential for the development of screening and support programs for at-risk workers to cater to their mental well-being. We recommend that the psychological impact of hand injuries be factored into holistic management and rehabilitation with adequate time and resource allocation. An ancillary benefit is the improvement of productivity and overall contribution to Singapore's economy.

Predictors of chronic pain and disability in patients treated conservatively after distal radius fracture: a prospective cohort study

PURPOSE

To determine predictors of chronic pain and disability among patients with distal radius fractures (DRF) treated conservatively with closed reduction and cast immobilization.

METHODS

This was a prospective cohort study. Information on patient characteristics, post-reduction radiographic parameters, finger and wrist range of motion, psychological status (Hospital Anxiety and Depression Scale or HADS), pain (Numeric Rating Scale or NRS), and self-perceived disability (Disabilities of the Arm, Should, and Hand or DASH) were taken at baseline, cast removal, and 24 weeks. Differences in outcomes between time points were determined using analysis of variance. Multiple linear regressions were used to determine predictors of pain and disability at 24 weeks.

RESULTS

One hundred forty patients with DRF (70% women, age: 67.0 ± 17.9) completed 24 weeks of follow-up and were included in the analysis. NRS (off-cast), range of ulnar deviation (off-cast), and greater occupational demands were significant predictors of pain at week 24 (adjusted R² = 0.331, p < 0.001). Significant predictors of perceived disability at week 24 were HADS (off cast), sex (female), dominant-hand injury, and range of ulnar deviation (off cast) (adjusted R² = 0.265, p < 0.001).

CONCLUSIONS

Off-cast NRS and HADS scores are important modifiable predictors of patient-reported pain and disability at 24 weeks in patients with DRF. These factors should be targeted in the prevention of chronic pain and disability post-DRF.

Association of psychological factors with limb disability in patients with cervical radiculopathy: comparison with carpal tunnel syndrome

Background

Regarding musculoskeletal conditions, patient’s psychological distress, are shown to be associated with higher disability. Cervical radiculopathy (CR) and carpal tunnel syndrome (CTS), are two conditions caused by entrapment of cervical nerve roots and carpal median nerve, respectively. This study aims to investigate the association of psychological factors including depression, anxiety, and pain catastrophizing, with measures of upper limb patient-reported and performance-based disability, in patients with CR, and compare the obtained results with our similar study on CTS.

Methods

In a cross-sectional study, we recruited 92 patients with CR, and investigated their disability level using patient-reported questionnaires (Quick Disabilities of the Arm, Shoulder and Hand (DASH) and pain Likert Scale) and by measuring grip and pinch strength. We also assessed their psychological status with Hospital Anxiety and Depression Scale questionnaire for depression (HADS-D) and anxiety (HADS-A) and also Pain Catastrophizing Scale (PCS) tools. We performed correlational coefficient analysis between disability and psychological scores and regression analysis of dependent variables (Pain, DASH, grip and pinch scores) and independent (psychological) variables. Finally, Z observed value was calculated to compare correlational coefficients between two diseases of CTS and CR.

Results

The results of the correlational coefficient analysis indicate that all three HADS-A, HADS-D and PCS scores correlated with DASH score (r = 0.49, 0.37, 0.38 for HADS-A, HADS-D and PCS, respectively; p < 0.001 for all three). HADS-A also significantly correlated with VAS pain score (r = 0.41, P < 0.001) and grip strength (r = − 0.25, P = 0.016). Linear regression analysis revealed that anxiety has a notable value for DASH and VAS pain scores as well as grip strength. Fisher’s r correlation coefficient to z transformation, revealed that there was no difference between two diseases of CTS and CR in terms of the resulted r coefficients from correlational coefficient analysis between disability and psychological distress.

Conclusion

It is concluded that psychological disorders are associated with disability in CR patients, with anxiety also correlating with objective disability parameter of grip strength. Finally, both CTS and CR patients’ disabilities associate with anxiety, depression, and catastrophysing thinking in a similar manner.

Level of evidence

Level IV (cross-sectional study).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05593-2.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials

OBJECTIVE

To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors.

STUDY SELECTION

Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation.

DATA SYNTHESIS

We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field.

RESULTS

Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct.

CONCLUSION

There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

The Influence of Pain and Resiliency on Foot and Ankle Surgery Outcomes

Background:

Resilience is the ability to recover after stressful events and has been shown to correlate with surgical outcomes. However, there has been minimal research on the impact of patient resiliency on foot and ankle surgical outcomes. This study aims to determine the predictive value of preoperative resiliency scores on surgical outcomes and investigate how this compares with the predictive value of pain scores.

Methods:

We conducted a retrospective review of adult patients who completed a preoperative Brief Resilience Scale (BRS) and underwent surgery between November 2019 and November 2020 with a fellowship-trained foot and ankle surgeon (N=184). Data included demographics, comorbidities, surgical details, complication and reoperation rates, pre- and postoperative opioid and benzodiazepine use, and additional patient-reported outcome measures (ie, visual analog scale [VAS], Pain Catastrophizing Scale [PCS], Pain Disability Index [PDI], Foot and Ankle Outcome Score [FAOS] pain subscale). Mean follow-up duration was 4.49 (range, 1.10-14.17) months.

Results:

BRS weakly correlated with decreased postoperative benzodiazepine use ( P=.007). PCS magnification ( P=.050) and helplessness ( P=.047) subscales weakly correlated with increased follow-up duration. PDI total score and most subscores significantly correlated with an increase in at least 1 of the following: follow-up duration, or postoperative opioid or benzodiazepine use. Neither the VAS nor FAOS pain subscore correlated with any outcome. PDI total score was the strongest predictor of postoperative opioid (β=0.334) and benzodiazepine (β=0.315) use. Preoperative opioid users had significantly higher PDI total score (user=39.3, nonuser=24.9; P=.012) and subscores (ie, social activity, sexual behavior, self-care, life-support activities).

Conclusion:

BRS is an unreliable tool for predicting outcomes in foot and ankle surgery, as it only weakly correlated with decreased benzodiazepine use. Rather, given the PDI’s strong associations with postoperative measures in this study, physicians should consider the value of preoperative PDI completion when predicting how foot and ankle surgery recipients will fare postoperatively.

Level of Evidence:

Level III, retrospective cohort study.

Priorities for Advancing Mental and Social Health Among People Presenting for Care of Musculoskeletal Symptoms : International Consortium for Mental and Social Health in Musculoskeletal Care

An international group of clinicians and researchers formed a consortium to advance mental and social health among people seeking musculoskeletal specialty care: The International Consortium for Mental and Social Health in Musculoskeletal Care (I-MESH). As a first step to organize the work of the consortium, we sought to identify important, appropriate, and feasible interventions to address mental and social health. Members of I-MESH responded to a list of 10 queries intended to elicit mental and social health priorities. Open text answers were analyzed by 2 researchers to elicit individual themes. A modified RAND/UCLA Delphi Appropriateness process was conducted of 32 candidate social and mental health priorities using a 15-person panel of I-MESH members, using 2 rounds of independent voting with intervening discussion via surveys and video teleconferences. Panelists rated each potential priority for importance, feasibility, and appropriateness on a 9-point Likert scale. Top level priorities scored both mean and median greater than 7 in all 3 categories. Second level priorities scored a median 7 or greater on the final scoring in all 3 categories. Candidate priorities were organized into 9 themes: viable business model, coordination of specialty and non-specialty care, actionable measurement, public health/cultural interventions, research, adequate and timely access, incorporating assessment in care, strategies to develop the patient-clinician relationship, communication strategies that can directly enhance health, and support for mental and social health. Twelve top level (met mean and median criteria) and 17 s level priorities (met median criterion) were identified. Implementing evidence-based strategies to efficiently diagnose, prioritize, and begin addressing mental and social health opportunities has the potential for notable impact on both musculoskeletal and overall health. It is our hope that the results of this Delphi panel will generate enthusiasm and collaboration for implementing the mounting evidence that social and mental health are integral to musculoskeletal health.

Prognostic Factors Affecting Long-Term Outcomes After Elbow Dislocation: A Longitudinal Cohort Study

Purpose

To describe patient-reported outcomes following simple elbow dislocation and to identify the baseline factors that predict outcomes.

Methods

Adult patients treated with a closed reduction for a simple elbow dislocation with or without minor fracture (coronoid avulsion, radial head fracture, or epicondyle avulsion) from 2000 to 2018 completed outcome instruments including Disabilities of the Arm, Shoulder and Hand (QuickDASH) via Research Electronic Data Capture. Descriptive statistics were calculated. Univariate followed by multivariate Tobit regression models were used to determine factors associated with clinical outcomes on QuickDASH. Social deprivation was measured using the Area Deprivation Index. Patients with additional upper-extremity injuries or associated major fractures (Monteggia or terrible triad injuries, distal humerus fractures, etc) were excluded.

Results

At a mean follow-up of 67.5 months, 95% (38/40) of patients reported satisfaction with treatment, and clinical outcomes were good (QuickDASH 9.0 ± 14.8). Univariate analysis showed that higher Area Deprivation Index, older age, female sex, high-energy mechanism of injury, and worker’s compensation (WC) or Medicare insurance status (vs commercial) was associated with significantly worse QuickDASH scores at follow-up. Early therapy, dominant elbow involvement, presence of minor fractures (minimally displaced radial head, coronoid tip, or epicondylar avulsion fractures), race, and treating service did not influence outcomes in univariate analyses. Multivariate analysis demonstrated a significant association between increased social deprivation, WC insurance, and Medicare insurance and worse QuickDASH scores while controlling for new upper-extremity injury, age, sex, and mechanism of injury.

Conclusions

Outcomes and treatment satisfaction following simple elbow dislocation are generally good but are significantly worse for the patients with greater levels of social deprivation and WC or Medicare insurance. Although surgeons should be aware of the possibility that specific subsets of patients may benefit from early therapy, this factor did not appear to influence long-term outcomes in this small cohort.

Type of study/level of evidence

Prognostic III.

Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation

Purpose

Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF.

Methods

Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score.

Results

Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern.

Conclusions

At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation.

Type of study/level of evidence

Prognostic IV.

Collagenase Clostridium histolyticum Injection Therapy Improves Health-related Quality of Life in Patients with Dupuytren's Disease

Objectives:

This study was conducted to investigate the changes in clinical and psychosocial outcomes in patients with Dupuytren’s disease after initial treatment with collagenase Clostridium histolyticum (CCH) injection.

Methods:

This study involved 14 patients with Dupuytren’s disease who underwent treatment with CCH injection. The range of motion of each phalangeal joint was measured before treatment and at 6 months posttreatment. The following assessments were also carried out pre- and posttreatment: the Geriatric Depression Scale Short – Japanese version (GDS-J) to evaluate depressive status, Hand 10 to assess hand health status, and EuroQol-5-dimension-3-level Japanese version to evaluate health-related quality of life

Results:

Significant improvements were found in metacarpophalangeal joint extension and proximal interphalangeal joint extension. Significant differences were also found between values before the initiation of CCH injection and those at 6 months posttreatment for the EuroQol index score and the EuroQol Visual Analog Scale (VAS). Significant positive correlations were found between the pre- to posttreatment change in GDS-J scores and for the change in Hand 10 scores. Moreover, a significant negative correlation was found between the change in GDS-J scores and change in EuroQol index scores/EuroQol VAS scores before and at 6 months after CCH injection.

Conclusions:

For patients with Dupuytren’s disease, CCH therapy directly improved the health-related quality of life. The degree of improvement of depressive status was associated with the degree of improvement of hand health status and health-related quality of life.

Impact of smoking on patient-reported outcome measures after arthroscopic rotator cuff repair: a 2-year comparative cohort study

Background and Hypothesis

Smoking is a well-established risk factor for tendon healing. The purpose of this study was to evaluate the differences in patient-reported outcome measures between smokers and nonsmokers who have undergone arthroscopic rotator cuff repair. It was hypothesized that smokers would have worse self-reported outcomes at 1 and 2 years postoperatively.

Methods

A total of 560 consecutive patients who underwent arthroscopic rotator cuff repair were divided into 2 groups: group I (smokers) n = 25 and group II (nonsmokers) n = 535. All participants were administered preoperative and postoperative surveys consisting of the following outcome-measuring tools: (i) visual analog scale, (ii) Veterans Rand 12-Item Health Survey, (iii) American Shoulder and Elbow Surgeons shoulder score, (iv) standard preoperative form consisting of 4 questions regarding their expectations of recovery, (v) Single Assessment Numeric Evaluation shoulder score, and (vi) Simple Shoulder Test.

Results

At 1 and 2 years postoperative, nonsmokers reported statistically significant differences in Veterans Rand 12-Item Health Survey mental scores (56.2 vs. 51.9, P = .0162 and 56.3 vs. 49.5, P = .0004, respectively). American Shoulder and Elbow Surgeons Shoulder scores showed no differences until the 2-year mark, at which time nonsmokers reported higher scores than smokers (87.9 vs. 79.0, P = .0212). Single Assessment Numeric Evaluation scores also remained similar up until 2-year follow-up, at which time nonsmokers reported statistically significant improvement (80.0 vs. 68.5, P = .0339). Nonsmokers reported higher Simple Shoulder Test scores at baseline and at 2-year follow-up (43.3 vs. 37.0, P = .0417 and 83.7 vs. 68.1, P = .0046, respectively).

Conclusion

At 2 years postoperatively, nonsmokers had significantly higher patient-reported outcome measure scores than smokers. In elective surgery, smoking status should be considered as a risk factor for poorer patient-reported outcomes after arthroscopic rotator cuff repair. However, smokers continue to report a clinical benefit at 2 years postoperatively.

Upper Extremity Function, Peer Relationships, and Pain Interference: Evaluating the Biopsychosocial Model in a Pediatric Hand Surgery Population Using PROMIS

PURPOSE

The relationship between biopsychosocial factors and patient-reported function is less clear in pediatric than in adult hand surgery patients. Our primary hypothesis was that pain interference (PI) and peer relationships (PR) would demonstrate association with upper extremity function. Secondarily, we hypothesized that the magnitude of this effect would increase with age.

METHODS

Patients aged 5 to 17 years presenting to a tertiary academic clinic between October 2017 and January 2019 were included. The parent/guardian was administered the following instruments after indicating they, rather than the patient, were answering the questions on a tablet computer: Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Parent Proxy (PP) Computer Adaptive Test (CAT) v2.0, PROMIS PI PP CAT v2.0, and the PROMIS PR PP CAT v2.0. Ceiling/floor effects and Spearman correlations were calculated. Multivariable Tobit modeling was performed to determine whether biopsychosocial factors and upper extremity function were associated. Multivariable regression coefficients were compared between age cohorts using a separate multivariable model to evaluate the interaction between age and other predictors.

RESULTS

Of 139 included participants, the mean age was 11.7 ± 3.7 years and 50% were female. For patients 11 years of age or younger, UE was weakly correlated with PI (coefficient, -0.34; 95% confidence interval, -0.56 to -0.08) and was not correlated with PR. For patients older than 11 years, UE had moderate correlation with PI (coefficient, -0.60; 95% confidence interval, -0.72 to -0.45) and was not correlated with PR. Multivariable analysis demonstrated a significant negative association between PI and UE, with a significantly larger magnitude of effect for patients older than 11 years of age.

CONCLUSIONS

The biopsychosocial model applies to pediatric hand surgery patients. The association between greater pain interference and worse patient-reported upper extremity function, as assessed using parent proxy instruments, was significantly stronger for patients older than 11 years than those 11 years old or younger.

CLINICAL RELEVANCE

This study suggests that the biopsychosocial model applies to pediatric hand patients.

Equivalent PROMIS Scores after Nonoperative or Operative Treatment of Trapeziometacarpal Osteoarthritis

Background

Patient-Reported Outcomes Measurement Information System (PROMIS) scores can quantify symptoms and limitations after upper extremity surgery. Our objective was to determine how these scores compare amongst patients with trapeziometacarpal osteoarthritis treated either nonoperatively or operatively.

Methods

In this retrospective comparative study, we compared PROMIS scores (upper extremity function [UEF], pain interference, and depression) between 43 patients who underwent nonoperative treatment (nonsteroidal anti-inflammatory drugs/splinting/injections) and 33 patients who underwent trapeziectomy with ligament reconstruction and tendon interposition for trapeziometacarpal osteoarthritis (minimum 6-month recovery period) by 4 surgeons from 2014-2018. PROMIS scores were compared across all patients by Eaton-Littler staging. We used linear regression to assess correlations between time-since-surgery and each PROMIS domain. Multivariable linear regression was used to identify patient and disease factors independently associated with PROMIS scores.

Results

Surgery was not associated with better UEF (37 vs. 40, P=0.23), less pain interference (58 vs. 56, P=0.42), or fewer symptoms of depression (47 vs. 46, P=0.59). Similarly, no differences were observed across all patient by Eaton-Littler stage for UEF (P=0.49), pain (P=0.48), or depression (P=0.90). For the operative group, greater time-since-surgery, or patient recovery period, correlated moderately with worse UEF (R=0.41) and increased pain (R=0.37).

Conclusion

In small retrospective comparative cohorts, surgery was not associated with better UEF, pain, or depression scores compared with nonoperative treatment for trapeziometacarpal osteoarthritis.

Effect of Psychotropic Medications on Hammertoe Reconstruction Outcomes

Background:

Hammertoe deformities can seriously affect activity level and footwear. The use of prescription, mood-altering medications is very common, with some estimates as high as 25% of the population. Mood disorders, especially depression, negatively affect the results of medical and operative treatments. This study assessed the relationship of mood-altering medication use with the outcomes and complications of operative reconstruction of hammertoes.

Methods:

Data were prospectively collected from 116 patients who underwent hammertoe reconstruction, including demographic information, medical history, the use of mood-altering psychotropic medications (antidepressants, anxiolytics, hypnotics, and mood stabilizers), and postoperative complications. Preoperative patient-reported outcomes were measured using the visual analog scale (VAS) for pain and Short Form Health Survey (SF-36), which were repeated at 1-year follow-up.

Results:

A total of 36.2% of patients were taking psychotropic medications. Medication and nonmedication groups had similar pain VAS and SF-36 Physical Component Summary (PCS) scores before and after surgery. Compared with nonmedication patients, patients on psychotropic medications had significantly lower SF-36 Mental Component Summary (MCS) scores preoperatively (P = .001) and postoperatively (P = .006), but no significant difference in the change in MCS (ΔMCS) from preoperative to postoperative. Psychotropic medication use was associated with superficial wound infections (P = .048), but not other complications.

Conclusions:

Patients taking psychotropic medications were equally likely to benefit from forefoot reconstruction as nonmedication patients. Preoperative and postoperative PCS and VAS were not significantly different between medication and nonmedication groups. Although the medication group had lower absolute MCS, they reported the same magnitude of improvement in MCS (ΔMCS) as the nonmedication group.

Level of Evidence:

Level II, prospective cohort study.

Preoperative Mental Health Has a Stronger Association with Baseline Self-Assessed Knee Scores than Defect Morphology in Patients Undergoing Cartilage Repair

OBJECTIVE

The purpose of this study was to assess potential correlations between the mental component summary of the Short Form-12 (SF-12 MCS), patient characteristics or lesion morphology, and preoperative self-assessed pain and function scores in patients undergoing autologous chondrocyte implantation (ACI).

DESIGN

A total of 290 patients underwent ACI for symptomatic cartilage lesions in the knee. One hundred and seventy-eight patients were included in this study as they completed preoperative SF-12, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scores. Age, sex, smoker status, body mass index, Worker's Compensation, previous surgeries, concomitant surgeries, number of defects, lesion location in the patella, and total defect size were recorded for each patient. Pearson's correlation and multivariate regression models were used to distinguish associations between these factors and preoperative knee scores.

RESULTS

The SF-12 MCS showed the strongest bivariate correlation with all KOOS subgroups (P < 0.001) (except KOOS Symptom; P = 0.557), Tegner (P = 0.005), Lysholm (P < 0.001), and IKDC scores (P < 0.001). In the multivariate regression models, the SF-12 MCS showed the strongest association with all KOOS subgroups (P < 0.001) (except KOOS Symptom; P = 0.91), Lysholm (P = 0.001), Tegner (P = 0.017), and IKDC (P < 0.001).

CONCLUSION

In patients with symptomatic cartilage defects of the knee, preoperative patient mental health has a strong association with self-assessed pain and functional knee scores. Further studies are needed to determine if preoperative mental health management can improve preoperative symptoms and postoperative outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

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

Background:

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

Purpose/Hypothesis:

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

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

Depression and Pain Interference Correlate With Physical Function in Patients Recovering From Hand Surgery

Background: Patient-reported outcome measures vary more than expected based on underlying pathology, in part due to the substantial influence of mood and coping strategies. Methods: This study addressed the primary null hypothesis that the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function score 1 month (range, 3-8 weeks) after hand surgery is not associated with PROMIS Depression and PROMIS Pain Interference scores prior to surgery, accounting for other factors. Using an institution-wide database of routinely collected patient-reported outcomes, we identified adult patients who underwent wrist ganglion excision, trapeziometacarpal arthroplasty, hand ganglion excision, trigger digit, De Quervain, and carpal tunnel release. Measures collected included the PROMIS Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We sought factors associated with postsurgical PROMIS Physical Function scores and change between preoperative and postoperative score using multivariable linear regression, accounting for age, sex, surgery type, provider, and time from surgery to postsurgical measurement. Results: Higher postoperative PROMIS Physical Function score was independently associated with lower PROMIS Pain Interference scores, lower PROMIS Depression scores, younger age, and treatment by provider team 3. Greater change in PROMIS Physical Function score was independently associated with greater PROMIS Pain Interference scores, greater time from surgery, and treatment by provider team 3. Conclusions: Mood and effective coping strategies affect the level of symptoms and limitations during recovery from hand surgery and represent important treatment opportunities for enhancing recovery.

Minimal Clinically Important Difference After Carpal Tunnel Release Using the PROMIS Platform

PURPOSE

In light of recently-proposed quality measures for carpal tunnel release (CTR), elucidating the minimal clinically important difference (MCID) for selected outcome measures will be important when interpreting treatment responses. Our purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the short Disabilities of the Arm, Shoulder, and Hand (QuickDASH) following CTR.

METHODS

Adult patients undergoing isolated unilateral CTR between July 2014 and October 2016 were identified. Outcomes included the PROMIS Upper Extremity (UE) Computer Adaptive Test (CAT), Physical Function (PF) CAT, QuickDASH, and Pain Interference (PI) CAT. For inclusion, pretreatment baseline (within 60 days of surgery) and postoperative (6-90 days) UE or PF CAT scores were required, as well as a response on a 5-point Likert scale to the question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" The MCID was calculated using SD and minimum detectable change (MDC) distribution methods.

RESULTS

In response to the Likert scale question, 88.6% of patients reported improvement at a mean of 14.8 days after surgery. The infrequency of patients reporting no change (5 of 44; 11.4%) precluded calculation of a statistically sound anchor-based MCID value. The MCID values, as calculated using the one-half SD method, were 3.6, 4.6, 10.4, and 3.4 for the UE CAT, PF CAT, QuickDASH, and PI CAT, respectively.

CONCLUSIONS

We have calculated MCID values for the UE CAT, PF CAT, QuickDASH, and PI CAT for patients undergoing CTR. Although the small number of patients reporting no change and minimal change after surgery precluded an anchor-based MCID calculation, we report estimates using the one-half SD method for the MCID following CTR.

CLINICAL RELEVANCE

These MCID estimates will be helpful when interpreting CTR clinical outcomes and for powering prospective trials.

Prevalence of upper limb pain and disability and its correlates with demographic and personal factors

Purpose

The present study aimed to assess the prevalence of upper limb pain and disability and to investigate potentially correlated factors among university students in Jordan.

Methods

This was a cross-sectional questionnaire-based survey study that was conducted among university students. The upper limb pain and disability were assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire. The DASH outcome questionnaire was distributed to 2100 students from the population of 2 public and 2 private universities in the north of Jordan. Demographic and personal information were collected. Data were analyzed using descriptive statistics and linear regression analysis.

Results

A total of 1929 DASH outcome questionnaires were returned, with a high response rate of 91.86%. The age of the subjects was between 18–28 years (52% male; 48% female). The majority of subjects (85.2%) used at least one smartphone. The majority of them had been using a smartphone for more than 5 years. The prevalence of upper limb pain and disability among university students was 24%. Several factors were found to be significantly connected with upper limb pain and disability among university students, such as smartphone use, computer use,  the presence of musculoskeletal problems, not living with their families, using public transport (bus), and daily housekeeping.

Conclusion

The results of this study can be used globally to promote the health and well-being of university students, improve their academic performance and future career. Identifying high-risk groups will assist in early identifications and prevention programs for upper limb pain and disability among university students.

Depression and Anxiety among Patients with Atraumatic Lateral Epicondylitis and Ulnar-Sided Wrist Pain

Background  Ulnar-sided wrist pain (UWP) and lateral epicondylitis (LE) are common disorders that can be difficult to treat. Depression and anxiety have been shown to modify patient symptoms, disability and pain. Questions/Purposes  The purpose of our study was to quantify the prevalence of depression and anxiety among patients with LE or UWP. A secondary aim was to determine if these patients report higher levels of pain upon presentation and if they are more likely to require occupational therapy. Patients and Methods  A retrospective chart review was conducted, and patients included those with LE or UWP, atraumatic in origin, ages 18 and over, and ongoing use of noninvasive treatment of LE or UWP. Results  Our final analysis included 97 patients of which 57 had LE, 34 had UWP, and 6 had both. The prevalence of a mood disorder was 34.0%. Anxiety and/or depression was more prevalent in patients with LE compared to UWP. The most common medication was alprazolam. Pain scores averaged 1.2 points higher in subjects with a history of a mental health disorder. After adjusting for age and sex, there was no significant association between prevalence of depression and/or anxiety and utilization of physical or occupational therapy. Conclusions  Patients with either LE, UWP or both along with depression and/or anxiety may be less likely to improve with traditional treatments. Future investigations are warranted focusing on the value of a multidisciplinary team consisting of a hand surgeon, behavioral therapist, or psychologist to optimize treatment response. Level of Evidence  This is a Level IV, case series study.

What Role Does Positive Psychology Play in Understanding Pain Intensity and Disability Among Patients with Hand and Upper Extremity Conditions?

BACKGROUND

A large body of research shows that psychologic distress and ineffective coping strategies substantially contribute to more severe pain and increased physical limitations among patients with orthopaedic disorders. However, little is known about the relationship between positive psychology (constructs that enable individuals to thrive and adapt to challenges) and pain and physical limitations in this population.

QUESTIONS/PURPOSES

(1) Which positive-psychology factors (satisfaction with life, gratitude, coping through humor, resilience, mindfulness, and optimism) are independently associated with fewer upper-extremity physical limitations after controlling for the other clinical and demographic variables? (2) Which positive-psychology factors are independently associated with pain intensity after controlling for relevant clinical and demographic variables?

METHODS

In a cross-sectional study, we recruited patients presenting for a scheduled appointment with an orthopaedic surgeon at a hand and upper-extremity clinic of a major urban academic medical center. Of 125 approached patients, 119 (44% men; mean age, 50 ± 17 years) met screening criteria and agreed to participate. Patients completed a clinical and demographic questionnaire, the Numerical Rating Scale to assess pain intensity, the Patient-reported Outcomes Measurement Information System (PROMIS) Upper Extremity Physical Function computerized adaptive test to assess physical limitations, and six measures assessing positive-psychology constructs: The Satisfaction with Life Scale, the Gratitude Questionnaire, the Coping Humor Scale, the Brief Resilience Scale, the Cognitive and Affective Mindfulness Scale-Revised, and the Life Orientation Test-Revised. We first examined bivariate associations among physical limitations, pain intensity, and all positive-psychology factors as well as demographic and clinical variables. All variables that demonstrated associations with physical limitations or pain intensity at p < 0.05 were included in two-stage multivariable hierarchical regression models.

RESULTS

After controlling for the potentially confounding effects of prior surgical treatment and duration since pain onset (step1; R total = 0.306; F[7,103] = 6.50), the positive-psychology variables together explained an additional 15% (R change = 0.145, F change [5, 103] = 4.297, p = 0.001) of the variance in physical limitations. Among the positive-psychology variables tested, mindfulness was the only one associated with fewer physical limitations (β = 0.228, t = 2.293, p = 0.024, 4% variance explained). No confounding demographic or clinical variables were found for pain intensity in bivariate analyses. All positive-psychology variables together explained 23% of the variance in pain intensity (R = 0.23; F[5,106] = 6.38, p < 0.001). Among the positive-psychology variables, satisfaction with life was the sole factor independently associated with higher intensity (β = -0.237, t = -2.16, p = 0.033, 3% variance explained).

CONCLUSIONS

Positive-psychology variables explained 15% of the variance in physical limitations and for 23% of the variance in pain intensity among patients with heterogenous upper extremity disorders within a hand and upper extremity practice. Of all positive-psychology factors, mindfulness and satisfaction with life were most important for physical limitations and pain intensity, respectively. As positive-psychology factors are more easily modifiable through skills-based interventions than pain and physical limitations, results suggest implementation of such interventions to potentially improve outcomes in this population. Skills-based interventions targeting mindfulness and satisfaction with life may be of particular benefit.

LEVEL OF EVIDENCE

Level II, prognostic study.

Outcomes Following Replantation/Revascularization in the Hand

The variability in reported outcomes and outcome measures used in digit replantation makes it difficult to compare results among studies. This article reviews the principles of measuring functional and patient-reported outcomes after replantation, and describes the recommended instruments to use and ways to report results.

The Relationship between Depression or Anxiety Symptoms and Objective and Subjective Symptoms of Patients with Frozen Shoulder

Background

the aim of this study is to evaluate the prevalence and effect of depression and anxiety on the shoulder range of motion, as well as the objective and subjective symptoms in patients suffering from frozen shoulder.

Methods

Between 2013 and 2014, in a cross-sectional study, we evaluated 120 patients with idiopathic frozen shoulder. We collected the demographic data for each patient and measured shoulder range of motion in four directions in both limbs. All patients filled out visual analog scale (VAS) for pain and the disabilities of the arm, shoulder, and hand (DASH) questionnaires. Both Hamilton anxiety and depression questionnaires were filled out for each patient.

Results

A total of 92 patients (77%) with idiopathic frozen shoulder showed symptoms of depression, while only 32 (27%) of them experienced anxiety. Thirty-two patients (27%) showed symptoms of both depression and anxiety. Although elevation and abduction were not affected by depression, internal and external rotations were more restricted among patients who had symptoms of depression. DASH and VAS scores were higher in patients with symptoms of depression. In terms of anxiety, only VAS and DASH were different between two groups. In multivariable analysis, DASH score was correlated with severity of both anxiety and depression symptoms.

Conclusion

While there is no definitive relationship between symptoms of depression or anxiety and shoulder range of motion in patients suffering from frozen shoulder, patients who suffer from depression or anxiety experienced increased pain and limb disability.

Can Patients Forecast Their Postoperative Disability and Pain?

BACKGROUND

Forecasting is a construct in which experiences and beliefs inform a projection of future outcomes. Current efforts to predict postoperative patient-reported outcome measures such as risk-stratifying models, focus on studying patient, surgeon, or facility variables without considering the mindset of the patient. There is no evidence assessing the association of a patient's forecasted postoperative disability with realized postoperative disability. Patient-forecasted disability could potentially be used as a tool to predict postoperative disability.

QUESTIONS/PURPOSES

(1) Do patient-forecasted disability and pain correlate with patient-realized disability and pain after hand surgery? (2) What other factors are associated with patient ability to forecast disability and pain?

METHODS

We completed a prospective, longitudinal study to assess the association between forecasted and realized postoperative pain and disability as a predictive tool. One hundred eighteen patients of one hand/upper extremity surgeon were recruited from November 2016 to February 2018. Inclusion criteria for the study were patients undergoing hand or upper extremity surgery, older than 18 years of age, and English fluency and literacy. We enrolled 118 patients; 32 patients (27%) dropped out as a result of incomplete postoperative questionnaires. The total number of patients eligible was not tracked. Eighty-six patients completed the preoperative and postoperative questionnaires. Exclusion criteria included patients unable to give informed consent, children, patients with dementia, and nonEnglish speakers. Before surgery, patients completed a questionnaire that asked them to forecast their upper extremity disability (DASH [the shortened Disabilities of the Arm, Shoulder and Hand] [QuickDASH]) and pain VAS (pain from 0 to 10) for 2 weeks after their procedure. The questionnaire also queried the following psychologic factors as explanatory variables, in addition to other demographic and socioeconomic variables: the General Self Efficacy Scale, the Pain Catastrophizing Scale, and the Patient Health Questionnaire Depression Scale. At the 2-week followup appointment, patients completed the QuickDASH and pain VAS to assess their realized disability and pain scores. Bivariate analysis was used to test the association of forecasted and realized disability and pain reporting Pearson correlation coefficients. Unpaired t-tests were performed to test the association of demographic variables (for example, men vs women) and the association of forecasted and realized disability and pain levels. One-way analysis of variance was used for variables with multiple groups (for example, annual salary and ethnicity). All p values < 0.05 were considered statistically significant.

RESULTS

Forecasted postoperative disability was moderately correlated with realized postoperative disability (r = 0.59; p < 0.001). Forecasted pain was weakly correlated with realized postoperative pain (r = 0.28; p = 0.011). A total of 47% of patients (n = 40) were able to predict their disability score within the MCID of their realized disability score. Symptoms of depression also correlated with increased realized postoperative disability (r = 0.37; p < 0.001) and increased realized postoperative pain (r = 0.42; p < 0.001). Catastrophic thinking was correlated with increased realized postoperative pain (r = 0.31; p = 0.004). Patients with symptoms of depression realized greater pain postoperatively than what they forecasted preoperatively (r = -0.24; p = 0.028), but there was no association between symptoms of depression and patients' ability to forecast disability (r = 0.2; p = 0.058). Patient age was associated with a patient's ability to forecast disability (r = .27; p = 0.011). Catastrophic thinking, self-efficacy, and number of prior surgical procedures were not associated with a patient's ability to forecast their postoperative disability or pain.

CONCLUSIONS

Patients undergoing hand surgery can moderately forecast their postoperative disability. Surgeons can use forecasted disability to identify patients who may experience greater disability compared with benchmarks, for example, forecast and experience high QuickDASH scores after surgery, and inform preoperative discussions and interventions focused on expectation management, resilience, and mindset.

LEVEL OF EVIDENCE

Level III, prognostic study.

Adverse Childhood Experiences Are Not Associated With Patient-reported Outcome Measures in Patients With Musculoskeletal Illness

BACKGROUND

Adverse childhood experiences (ACEs) affect adult mental health and tend to contribute to greater symptoms of depression and more frequent suicide attempts. Given the relationship between symptoms of depression and patient-reported outcomes (PROs), adversity in childhood might be associated with PROs in patients seeking care for musculoskeletal problems, but it is not clear whether in fact there is such an association among patients seeking care in an outpatient, upper extremity orthopaedic practice.

QUESTIONS/PURPOSES

(1) Are ACE scores independently associated with variation in physical limitations measured among patients seen by an orthopaedic surgeon? (2) Are ACE scores independently associated with variations in pain intensity? (3) What factors are associated with ACE scores when treated as a continuous variable or as a categorical variable?

METHODS

We prospectively enrolled 143 adult patients visiting one of seven participating orthopaedic surgeons at three private and one academic orthopaedic surgery offices in a large urban area. We recorded their demographics and measured ACEs (using a validated 10-item binary questionnaire that measured physical, emotional, and sexual abuse in the first 18 years of life), magnitude of physical limitations, pain intensity, symptoms of depression, catastrophic thinking, and health anxiety. There were 143 patients with a mean age of 51 years, 62 (43%) of whom were men. In addition, 112 (78%) presented with a specific diagnosis and most (n = 79 [55%]) had upper extremity symptoms. We created one logistic and three linear regression models to test whether age, gender, race, marital status, having children, level of education, work status, insurance type, comorbidities, body mass index, smoking, site of symptoms, type of diagnosis, symptoms of depression, catastrophic thinking, and health anxiety were independently associated with (1) the magnitude of limitations; (2) pain intensity; (3) ACE scores on the continuum; and (4) ACE scores categorized (< 3 or ≥ 3). We calculated a priori that to detect a medium effect size with 90% statistical power and α set at 0.05, a sample of 136 patients was needed for a regression with five predictors if ACEs would account for ≥ 5% of the variability in physical function, and our complete model would account for 15% of the overall variability. To account for 5% incomplete responses, we enrolled 143 patients.

RESULTS

We found no association between ACE scores and the magnitude of physical limitations measured by Patient-Reported Outcomes Measurement Information System Physical Function (p = 0.67; adjusted R = 0.55). ACE scores were not independently associated with pain intensity (Pearson correlation [r] = 0.11; p = 0.18). Greater ACE scores were independently associated with diagnosed mental comorbidities both when analyzed on the continuum (regression coefficient [β] = 1.1; 95% confidence interval [CI], 0.32-1.9; standard error [SE] 0.41; p = 0.006) and categorized (odds ratio [OR], 3.3; 95% CI, 1.2-9.2; SE 1.7; p = 0.024), but not with greater levels of health anxiety (OR, 1.1; 95% CI, 0.90-1.3; SE 0.096; p = 0.44, C statistic = 0.71), symptoms of depression (ACE < 3 mean ± SD = 0.73 ± 1.4; ACE ≥ 3 = 1.0 ± 1.4; p = 0.29) or catastrophic thinking (ACE < 3 = 3.6 ± 3.5; ACE ≥ 3 = 4.9 ± 5.1; p = 0.88).

CONCLUSIONS

ACEs may not contribute to greater pain intensity or magnitude of physical limitations unless they are accompanied by greater health anxiety or less effective coping strategies. Adverse events can contribute to anxiety and depression, but perhaps they sometimes lead to development of resilience and effective coping strategies. Future research might address whether ACEs affect symptoms and limitations in younger adult patients and patients with more severe musculoskeletal pathology such as major traumatic injuries.

LEVEL OF EVIDENCE

Level II, prognostic study.

Mental Health Has No Predictive Association With Self-Assessed Knee Outcome Scores in Patients After Osteochondral Allograft Transplantation of the Knee

Background:

Patient-reported outcome (PRO) measures are progressively utilized as evaluation tools in preoperative and postoperative assessments in orthopaedic practice. Identifying the potential utility of psychosocial factors to predict patient-reported pain and functional outcomes is of increasing interest to determine which patients will derive the greatest benefit from surgical treatment.

Purpose/Hypothesis:

The purpose of this study was to determine potential predictive associations between the preoperative 12-Item Short Form Health Survey Mental Component Summary (SF-12 MCS) score, patient characteristics or osteochondral allograft (OCA) morphology, and PROs in patients who underwent OCA transplantation. We hypothesized that poor preoperative mental health is associated with diminished PROs at final follow-up.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A total of 67 patients with a mean follow-up of 2.7 ± 1.0 years (range, 2-6 years) with complete preoperative and at least 24-month postoperative SF-12 MCS, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scores were included in this study. Pearson correlation coefficients and linear regression models were used to distinguish associations between age, sex, smoking status, body mass index, workers’ compensation, previous surgery, concomitant surgery, number of grafts, defect location, total graft size, SF-12 MCS score, and postoperative PRO scores as well as their improvement from baseline (delta).

Results:

The SF-12 MCS showed significant correlation with the KOOS Activities of Daily Living subscale (P = .015), KOOS Sport/Recreation subscale (P = .024), and IKDC (P = .039). In the multivariable linear regression models, the SF-12 MCS had no predictive association with any PRO measure. Patient sex contributed significantly to the final regression models of the KOOS Sport/Recreation (P = .042), Tegner score (P = .024), and Lysholm score (P = .031). The SF-12 MCS showed no bivariate correlation with changes in any PRO score (delta) (P > .05).

Conclusion:

Preoperative mental health status did not predict perceived functional outcomes as assessed by PRO measures at final follow-up. Female sex was negatively correlated with KOOS Sport/Recreation, Tegner, and Lysholm scores.

Using Patient-reported Outcomes Measurement Information System Measures to Understand the Relationship Between Improvement in Physical Function and Depressive Symptoms

INTRODUCTION

This investigation determined whether improved physical function and decreased pain would reduce depressive symptoms using the Patient-reported Outcomes Measurement Information System (PROMIS).

METHODS

This cohort study analyzed PROMIS Depression, Physical Function, and Pain Interference CAT scores from 3,339 patients presenting to a tertiary orthopaedic center. Patients demonstrating at least a-five point (effect size, 0.5) improvement in PROMIS Physical Function between consecutive visits were eligible for inclusion.

RESULTS

Patients presented, on average, with Physical Function and Pain Interference scores nearly one SD worse than population averages and Depression scores that approximated the normal population. Improved Physical Function and Pain Interference scores demonstrated no correlation with change in Depression scores (r = -0.13; r = 0.25).

CONCLUSION

Substantial early improvement in PROMIS Physical Function scores is not associated with change in PROMIS Depression scores. PROMIS Depression scores likely reflect underlying mental health rather than situational depressive symptoms.

LEVEL OF EVIDENCE

Prognostic, level III.

Association of Psychiatric Diagnostic Conditions with Hospital Care Outcomes of Patients with Orthopedic Injuries

CONTEXT

Psychiatric comorbidity is common in orthopedic injury, but the effects on hospital care outcomes have been identified only generally.

OBJECTIVE

To quantify psychiatric comorbidity and its outcome effects in a large, multicenter population of inpatients with orthopedic injuries.

DESIGN

Retrospective analysis of patient discharge data from 507 California hospitals from 2001 to 2010. Study sample included orthopedic diagnoses using International Classification of Diseases codes for major pelvic and lower extremity injuries in patients older than age 17 years. From the injury data, we extracted psychiatric diagnoses, alcoholism, substance abuse, and sociodemographic characteristics.

MAIN OUTCOME MEASURES

Length of stay, surgical complications, and inpatient deaths.

RESULTS

The entire injury admissions represented about 1.9% of all hospital admissions and were predominantly older than age 64 years, white, and women with conventional health care insurance. The most common comorbidity in the patients with injury was psychiatric illness (24.7%). The most common psychiatric diagnoses in orthopedic injury admissions were dementia (14.3%) and depression (6.9%) without association. Compared with the injury admissions with no psychiatric diagnosis, admissions with psychiatric diagnosis had higher odds of a hospital stay of 7 or more days, surgical treatment complications, and inhospital death.

CONCLUSION

Psychiatric comorbidity adversely affects several hospital outcomes in patients with orthopedic injuries: Length of stay, surgical complications, and inpatient mortality. In low-income populations, the adverse psychiatric effects are incrementally worse. The adverse effects of psychiatric comorbidity, particularly dementia and depression, on hospital outcomes should stimulate improved psychiatric care of many patients at risk of poor clinical outcomes.

What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review

BACKGROUND

Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.

QUESTIONS/PURPOSES

(1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients' upper extremity injuries?

METHODS

We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the "upper extremity", "outcome measurement", and "impairment, psychological, social or symptomatic" variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.

RESULTS

Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.

CONCLUSIONS

Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Psychological symptoms and the MCID of the DASH score in shoulder surgery

BACKGROUND

Psychological symptoms are frequently present in patients scheduled for shoulder surgery. The perception of functional disability, activity level and pain in the shoulder is negatively influenced by psychological symptoms, which leads to higher scores of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The aim of this study was to determine the influence of psychological symptoms on the minimal clinically important difference (MCID) of the DASH score in patients after shoulder surgery.

METHODS

In this prospective longitudinal cohort study, 176 patients were included. Group 1 (32 patients) had symptoms of psychological disorders before and after surgery; group 2 had no symptoms of psychological disorders (110 patients). In the remaining patients (34 patients), psychological disorders changed after surgery. Clinical outcome was measured with the change of DASH score and anchor questions for perceived improvement of pain and function after surgery. Symptoms of psychological disorders were identified with the Four-Dimensional Symptom Questionnaire. An anchor-based mean change score technique was used to determine the MCID of the DASH score.

RESULTS

DASH scores before and 12 months after shoulder surgery were significantly higher in patients with symptoms of psychological disorders; change of DASH score was not different between the two groups. The MCID of the DASH score was 13.0 [SD 20.7] in the group with symptoms of psychological disorders and 12.7 [SD 17.6] in the group with no symptoms of psychological disorders. We observed no difference (p = 0.559) in the MCID between the group with and the group without symptoms of psychological disorders.

CONCLUSION

Symptoms of psychological disorders had a negative effect on the DASH score but no influence on the MCID of the DASH score. The DASH score could be used in future studies to assess the influence of psychological factors on the clinical outcome of treatment.

The PROMIS Global Health Questionnaire Correlates With the QuickDASH in Patients With Upper Extremity Illness

BACKGROUND

The objective of this study is to evaluate the construct validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health instrument by establishing its correlation to the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire in patients with upper extremity illness.

METHODS

A cohort of 112 patients completed a sociodemographic survey and the PROMIS Global Health and QuickDASH questionnaires. Pearson correlation coefficients were used to evaluate the association of the QuickDASH with the PROMIS Global Health items and subscales.

RESULTS

Six of the 10 PROMIS Global Health items were associated with the QuickDASH. The PROMIS Global Physical Health subscale showed moderate correlation with QuickDASH and the Mental Health subscale. There was no significant relationship between the PROMIS Global Mental Health subscale and QuickDASH.

CONCLUSIONS

The consistent finding that general patient-reported outcomes correlate moderately with regional patient-reported outcomes suggests that a small number of relatively nonspecific patient-reported outcome measures might be used to assess a variety of illnesses. In our opinion, the blending of physical and mental health questions in the PROMIS Global Health makes this instrument less useful for research or patient care.

Association of Physical Function, Anxiety, and Pain Interference in Nonshoulder Upper Extremity Patients Using the PROMIS Platform

PURPOSE

The relationship between psychosocial factors and self-reported physical function among hand and upper extremity patients is complex. The Patient-Reported Outcomes Measurement Information System (PROMIS) platform has attempted to create a variety of specifically targeted metrics that can be administered using computer adaptive testing (CAT). Three metrics measuring self-reported physical function (herein referred to in combination as "functional" metrics) include the PROMIS Physical Function (PF) CAT, PROMIS Upper Extremity (UE) CAT, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). Two metrics assessing psychosocial factors include the PROMIS Anxiety and Pain Interference (PI) CATs ("nonfunctional" metrics). This study evaluates whether the functional metrics were correlated with nonfunctional metrics.

METHODS

The 5 questionnaires were administered prospectively on a tablet computer to all consecutive adult patients presenting to an outpatient hand and upper extremity (nonshoulder) clinic at a tertiary academic medical center from January 1 to November 1, 2014. For patients with multiple visits during the study period, only the first was included. Data were evaluated retrospectively to assess the relationship between functional and nonfunctional measures, with Pearson correlation coefficients to understand the relationship between continuous variables, and 1-way analysis of variance to examine for differences in outcome measures across demographic groups. Multivariable linear regression analyses were performed to determine factors predicting functional disability.

RESULTS

We included 1,299 patients: mean age was 46.8 years, 53% were female, and 23% were unemployed or on disability. The PROMIS PF CAT, PROMIS UE CAT, and QuickDASH scores were all significantly correlated with PROMIS Anxiety CAT (Pearson correlation coefficients, -0.46, -0.48, and 0.53, respectively) and PROMIS PI CAT (-0.60, -0.65, and 0.76, respectively) scores. Multivariable regression analyses demonstrated that increased PROMIS Anxiety and PI CAT scores each independently and adversely influenced PROMIS PF CAT, PROMIS UE CAT, and QuickDASH scores.

CONCLUSIONS

Increasing levels of patient anxiety and pain interference are independently associated with decreased patient-reported upper extremity function.

CLINICAL RELEVANCE

This study provides further support of the biopsychosocial model by highlighting that increased anxiety is associated with decreased self-reported function using the PROMIS platform.

Predicting outcome in frozen shoulder (shoulder capsulitis) in presence of comorbidity as measured with subjective health complaints and neuroticism

BACKGROUND

There is a substantive lack of knowledge about comorbidity in patients with frozen shoulder. The aim of this study was to investigate whether subjective health complaints and Neuroticism would predict treatment outcome in patients diagnosed with frozen shoulder as measured by the Shoulder Pain and Disability Index (SPADI) and change in SPADI.

METHODS

A total of 105 patients with frozen shoulder were recruited for a randomised controlled trial, where 69 were in the intervention group and received intraarticular corticosteroid injections and 36 patients served as control group. The SPADI was used as the outcome measure after 8 weeks, and change in SPADI from baseline to 8 weeks as a measure of rate of recovery. To examine comorbidities, all participants completed the Subjective Health Complaints (SHC) questionnaire with its five subscales, and the Neuroticism (N) component of the Eysenck Personality Questionnaire Revised. Multiple regression analysis was performed with the baseline comorbidity variables that correlated significantly with SPADI after 8 weeks, and with change in SPADI from baseline to 8 weeks, controlling for the variables intervention, age, gender and duration of pain.

RESULTS

In this study, patients with frozen shoulder had little comorbidity as measured with SHC and scored normally with respect to Neuroticism. Only the Pseudoneurology subscale in SHC correlated significantly with SPADI and had significant predictive power (p < 0.001) for the outcome at 8 weeks. The intervention group exhibited significant statistical predictive power (p < 0.001) for the treatment outcome as measured by a change in SPADI from baseline to 8 weeks. Being female also had some predictive significance for change in SPADI (p < 0.005).

CONCLUSION

Psychometric parameters as measured by the Pseudoneurology subscale in SHC questionnaire did predict the treatment outcome in frozen shoulder as measured by SPADI at 8 weeks, but not by change in SPADI from baseline to 8 weeks. One may conclude that psychometric parameters may affect symptoms, but do not predict the rate of recovery in frozen shoulder.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT01570985 .

Trajectories in quality of life of patients with a fracture of the distal radius or ankle using latent class analysis

Purpose

This prospective study aimed to identify the different trajectories of quality of life (QOL) in patients with distal radius fractures (DRF) and ankle fractures (AF). Secondly, it was examined if subgroups could be characterized by sociodemographic, clinical, and psychological variables.

Methods

Patients (n = 543) completed the World Health Organization Quality of Life assessment instrument-Bref (WHOQOL-Bref), the pain, coping, and cognitions questionnaire, NEO-five factor inventory (neuroticism and extraversion), and the state-trait anxiety inventory (short version) a few days after fracture (i.e., pre-injury QOL reported). The WHOQOL-Bref was also completed at three, six, and 12 months post-fracture. Latent class trajectory analysis (i.e., regression model) including the Step 3 method was performed in Latent Gold 5.0.

Results

The number of classes ranged from three to five for the WHOQOL-Bref facet and the four domains with a total variance explained ranging from 71.6 to 79.4%. Sex was only significant for physical and psychological QOL (p < 0.05), whereas age showed significance for overall, physical, psychological, and environmental QOL (p < 0.05). Type of treatment or fracture type was not significant (p > 0.05). Percentages of chronic comorbidities were 1.8 (i.e., social QOL) to 4.5 (i.e., physical QOL) higher in the lowest compared to the highest QOL classes. Trait anxiety, neuroticism, extraversion, pain catastrophizing, and internal pain locus of control were significantly different between QOL trajectories (p < 0.05).

Conclusions

The importance of a biopsychosocial model in trauma care was confirmed. The different courses of QOL after fracture were defined by several sociodemographic and clinical variables as well as psychological characteristics. Based on the identified characteristics, patients at risk for lower QOL may be recognized earlier by health care providers offering opportunities for monitoring and intervention.

A Systematic Review of Outcome Measures Assessing Disability Following Upper Extremity Trauma

Objectives

To define upper extremity outcome measures focusing on trauma and level of initial psychometric evaluation and to assess methodological quality of relevant patient-reported outcome (PRO) measures.

Data Sources

A broad search strategy using PubMed, OVID, CINAHL, and PsycINFO was deployed and reported using PRISMA (PROSPERO: CRD42016046243).

Study Selection Extraction Synthesis

PRO measures involving orthopedic trauma in their original development were selected and original publications assessed, including psychometric evaluations. Extraction, synthesis, and quality assessment were performed using COSMIN.

Results

Of 144 upper extremity outcome measures, the majority were designed for the shoulder, wrist, and hand; 20% (n = 29/144) involved trauma conditions in their initial development, PRO measurements, and psychometric evaluation on introduction. Methodological quality was highly variable.

Conclusion

A few PRO measures were originally designed for use in upper extremity trauma. Methodological quality and psychometric evaluation need to improve. This review aims to highlight strengths and weaknesses and guide decision making in this field.

The relation between elbow range of motion and patient satisfaction after open release of stiff elbow

Objective

The aim of this retrospective study was to find out whether a cut off value existed for elbow flexion and extension after open surgical release of elbow contracture that would correlate with subjective patient satisfaction.

Methods

The study enrolled 77 patients (53 males and 24 females with a mean age of 35.1 (18–77) years at the time of operation) with elbow contracture who attended regular follow-up appointments for more than 12 months. The mean follow up period was 44.2 months (12–186). The preoperative and postoperative modified MAYO elbow scores, objective parameters of increase in both flexion and extension end point measurements and improvement in total ROM were compared in order to determine the cut off degree of ROM in both flexion and extension that significantly correlated with patient satisfaction.

Results

Of the 77 participating patients, 26 patients had an extrinsic (33.8%) and 51 patients had an intrinsic elbow contracture (66.2%). Surgeries performed involved 40 cases of lateral release and 37 cases of both lateral and medial (progressive) release. The median preoperative total flexion-extension arch (ROM) was 45° (20°–65°). The median postoperative total flexion-extension arch (ROM) was 110° (97.5°–125°). The modified MAYO elbow score improved from 60 to 85 points postoperatively. The postoperative flexion cut off value was 115° for an excellent or good postoperative modified MAYO elbow score.

Conclusion

Post-operative flexion cut off value was 115° and had a positive effect on the postoperative patient satisfaction. The cut off value for postoperative extension was 20° but it was not a significant variable on patient satisfaction as was the total increase in ROM.

Level of significance

Level IV Therapeutic Study.

Emotional Support, Depressive Symptoms, and Age-Related Alterations in Male Body Composition: Cross-Sectional Findings from the Men's Health 40+ Study

More depressive symptoms and low emotional support have been related to worse body composition. Body composition significantly deteriorates in aging men. Therefore, we aimed to examine whether high emotional support and low depressive symptoms are associated with better body composition and a decelerated age-related deterioration of body composition in aging men. A cross-sectional analysis including 269 self-reporting healthy men aged between 40 and 75 years living in the German-speaking part of Switzerland was conducted. Participants completed questionnaires on emotional support and depressive symptoms. The depression screening instrument was used to form a group with low (N = 225) and moderate (N = 44) depressive symptoms. Body mass index (BMI) and waist-to-hip ratio (WHR) were measured, and cell proportion (CP), fat mass (FM), and water balance (WB) were obtained using bioelectrical impedance analysis. Age-related associations emerged for WHR, CP, FM, and WB, but not for BMI. Emotional support was negatively associated with BMI, WHR, and WB, and only trend-wise with CP and FM. Group comparisons revealed that more depressive symptoms were associated with lower levels of CP and higher levels of WB. Both emotional support and depressive symptoms were significant moderators of the association between age and specific measures of body composition such as CP, FM, and WB. However, after correction for multiple testing for moderation analyses only the moderation effects of depressive symptoms on the association between age and WB and CP remained significant. Low depressive symptoms were associated with a better body composition as well as a decelerated decline in body composition and the role of emotional support acting as a buffer against age-related deterioration of body composition merits further investigation.

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.

Lifetime prevalence of and factors associated with non-traumatic musculoskeletal pains amongst surgeons and patients

PURPOSE

There is evidence that surgeons make different recommendations for people seeking their care than they make for themselves. There may also be differences in pain episodes and management strategies between surgeons and people seeking care, knowledge of which might improve care. We aimed to assess whether the prevalence of non-traumatic pains, treatments and other factors differed between patients and surgeons.

MATERIALS AND METHODS

Two-hundred and twenty surgeons, members of the Science of Variation Group (SOVG), and 248 patients seeking care at the Hand Service at a large academic hospital completed a survey regarding the lifetime incidence of non-traumatic pains lasting > one month using short versions of the Pain Catastrophising Scale (PCS-4); Patient Health Questionnaire (PHQ-2); and Short Health Anxiety Inventory (SHAI-5).

RESULTS

Surgeons had a higher prevalence of at least one non-traumatic pain than patients and were more likely to report pain at more than one anatomical site. Patients were more likely to receive any treatment: surgery; injection; non-opioid medication; opioid medication; physical or occupational therapy. Patients missed work more often than surgeons. Age was the only factor independently associated with patient pain. Practicing in the United States was the only factor independently associated with surgeon pain.

CONCLUSIONS

Non-traumatic pains are extremely common. Surgeons have particularly effective coping strategies, allowing them to maintain their life roles with limited medical care when in pain. Increasing the appeal and availability of methods for optimising coping strategies might help to narrow the gap between surgeon and patient health.

The Influence of Preoperative and Postoperative Psychological Symptoms on Clinical Outcome after Shoulder Surgery: A Prospective Longitudinal Cohort Study

Background

Psychological symptoms are highly prevalent in patients with shoulder complaints. Psychological symptoms in patients with shoulder complaints might play a role in the aetiology, perceived disability and pain and clinical outcome of treatment. The aim of this study was to assess whether preoperative symptoms of distress, depression, anxiety and somatisation were associated with a change in function after shoulder surgery and postoperative patient perceived improvement of pain and function. In addition, the change of psychological symptoms after shoulder surgery was analyzed and the influence of postoperative symptoms of psychological disorders after surgery on the change in function after shoulder surgery and perceived postoperative improvement of pain and function.

Methods and Findings

A prospective longitudinal cohort study was performed in a general teaching hospital. 315 consecutive patients planned for elective shoulder surgery were included. Outcome measures included change of Disabilities of the Arm, Shoulder and Hand (DASH) score and anchor questions about improvement in pain and function after surgery. Psychological symptoms were identified before and 12 months after surgery with the validated Four-Dimensional Symptom Questionnaire (4DSQ). Psychological symptoms were encountered in all the various shoulder diagnoses. Preoperative symptoms of psychological disorders persisted after surgery in 56% of patients, 10% of patients with no symptoms of psychological disorders before surgery developed new psychological symptoms. Preoperative symptoms of psychological disorders were not associated with the change of DASH score and perceived improvement of pain and function after shoulder surgery. Patients with symptoms of psychological disorders after surgery were less likely to improve on the DASH score. Postoperative symptoms of distress and depression were associated with worse perceived improvement of pain. Postoperative symptoms of distress, depression and somatisation were associated with worse perceived improvement of function.

Conclusions

Preoperative symptoms of distress, depression, anxiety and somatisation were not associated with worse clinical outcome 12 months after shoulder surgery. Symptoms of psychological disorders before shoulder surgery persisted in 56% of patients after surgery. Postoperative symptoms of psychological disorders 12 months after shoulder surgery were strongly associated with worse clinical outcome.

Clinician and Patient-reported Outcomes Are Associated With Psychological Factors in Patients With Chronic Shoulder Pain

BACKGROUND

Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors.

QUESTIONS

We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements?

METHODS

All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5-15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes.

RESULTS

Greater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25-1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, -6.15; 95% CI, -11.09 to -1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021-0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87-0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77-16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, -0.35; 95% CI, -0.58 to -0.12; p = 0.003).

CONCLUSIONS

Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score.

LEVEL OF EVIDENCE

Level III, prognostic study.

The ability of preoperative factors to predict patient-reported disability following surgery for rotator cuff pathology

PURPOSE

Minimal research has examined the prognostic ability of shoulder examination data or psychosocial factors in predicting patient-reported disability following surgery for rotator cuff pathology. The purpose of this study was to examine these factors for prognostic value in order to help clinicians and patients understand preoperative factors that impact disability following surgery.

METHODS

Sixty-two patients scheduled for subacromial decompression with or without supraspinatus repair were recruited. Six-month follow-up data were available for 46 patients. Patient characteristics, history of the condition, shoulder impairments, psychosocial factors, and patient-reported disability questionnaires were collected preoperatively. Six months following surgery, the Western Ontario Rotator Cuff Index (WORC) and global rating of change dichotomized subjects into responders versus nonresponders. Logistic regression quantified prognostic ability and created the most parsimonious model to predict outcome.

RESULTS

Being on modified job duty (OR = .17, 95%CI: 0.03-0.94), and having a worker's compensation claim (OR = 0.08, 95%CI: 0.01-0.74) decreased probability of a positive outcome, while surgery on the dominant shoulder (OR = 11.96, 95%CI: 2.91-49.18) increased probability. From the examination, only impaired internal rotation strength was a significant univariate predictor. The Fear-avoidance Beliefs Questionnaire (FABQ) score (OR = 0.95, 95%CI: 0.91-0.98) and the FABQ_work subscale (OR = 0.92, 95%CI: 0.87-0.97) were univariate predictors. In the final model, surgery on the dominant shoulder (OR = 8.9, 95%CI 1.75-45.7) and FABQ_work subscale score ≤25 (OR = 15.3, 95%CI 2.3-101.9) remained significant.

DISCUSSION

Surgery on the dominant arm resulted in greater improvement in patient-reported disability, thereby increasing the odds of a successful surgery. The predictive ability of the FABQ_work subscale highlights the potential impact of psychosocial factors on patient-reported disability. Implications for Rehabilitation Impairment-based shoulder measurements were not strong predictors of patient-reported outcome. Having high fear-avoidance behavior scores on the FABQ, especially the work subscale, resulted in a much lower chance of responding well to rotator cuff surgery as measured by self-reported disability. Having surgery on the dominant shoulder, as compared to the nondominant side, resulted in larger improvements in disability levels.

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.

Prevalence of Symptoms of Depression, Anxiety, and Posttraumatic Stress Disorder in Workers With Upper Extremity Complaints

Study Design Cross-sectional cohort study. Background Symptoms of depression, panic disorder (PD), and posttraumatic stress disorder (PTSD) have been associated with musculoskeletal complaints and could represent barriers to recovery in injured workers. Objectives To determine the prevalence of symptoms of depression, PD, and PTSD utilizing the Patient Health Questionnaire (PHQ) in a cohort of patients presenting to an upper extremity injured-worker clinic; secondarily, to identify any relationships between patients screening positive and patient-reported outcome measures. Methods In 2010, 418 patients completed the PHQ during their initial evaluation. Patients with PHQ scores exceeding threshold values for symptoms of depression, PD, or PTSD were compared based on patient-reported outcome scores, including the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). The prevalence of symptoms, and their relationship with presenting complaints and patient-reported outcomes, were calculated. Results Thirty-one percent of patients scored above thresholds for symptoms of at least 1 mental health disorder. Of those who screened positive, 67% screened positive for depression, 44% for PTSD, and 50% for PD, with 43% of patients positive for multiple symptoms. Patients experiencing neck pain had significantly higher screening rates of depressive symptoms (62.5% versus 20.1%, P = .004) and PD (37.5% versus 12.9%, P = .044) compared with other presenting complaints. Similarly, patients with chronic pain had higher rates of depression (54.5% versus 20.1%, P = .006), PD (63.6% versus 12%, P<.001), and PTSD (36.4% versus 14.8%, P = .05) compared with other presenting complaints. Patients endorsing depressive symptoms had significantly lower SF-36 mental component summary scores (26.3 ± 10.7 versus 37.6 ± 9.9, P<.001) and higher shortened-version DASH (72.3 ± 16.7 versus 61.5 ± 11.1, P = .003) and DASH work scores (86.5 ± 19.2 versus 82.1 ± 20.1, P = .007) compared to patients endorsing other items on the PHQ. Conclusion In this prospective cohort study of injured workers, we identified a relatively high prevalence of symptoms of psychological disorders utilizing the PHQ, with one third of injured workers screening positive for symptoms of depression, PD, or PTSD. Further longitudinal follow-up is necessary to determine the impact on treatment outcomes. Level of Evidence Symptom prevalence, level 1b. J Orthop Sports Phys Ther 2016;46(7):590-595. Epub 12 May 2016. doi:10.2519/jospt.2016.6265.

Measuring arm function early after stroke: is the DASH good enough?

OBJECTIVE

Despite a growing call to use patient-reported outcomes in clinical research, few are available for measuring upper limb function post-stroke. We examined the Disabilities of the Arm, Shoulder and Hand (DASH) to evaluate its measurement performance in acute stroke. In doing so, we compared results from traditional and modern psychometric methods.

METHODS

172 people with acute stroke completed the DASH. Those with upper limb impairments completed the DASH again at 6 weeks (n=99). Data (n=271) were analysed using two psychometric paradigms: traditional psychometric (Classical Test Theory, CTT) analyses examined data completeness, scaling assumptions, targeting, reliability and responsiveness; Rasch Measurement Theory (RMT) analyses examined scale-to-sample targeting, scale performance and person measurement.

RESULTS

CTT analyses implied the DASH was psychometrically robust in this sample. Data completeness was high, criteria for scaling assumptions were satisfied (item-total correlations 0.55-0.95), targeting was good, internal consistency reliability was high (Cronbach's α=0.99) and responsiveness was clinically moderate (effect size=0.51). However, RMT analyses identified important limitations: scale-to-sample targeting was suboptimal, 4 items had disordered response category thresholds, 16 items exhibited misfit, 3 pairs of items had high residual correlations (>0.60) and 84 person fit residuals exceeded the recommended range.

CONCLUSIONS

RMT methods identified limitations missed by CTT and indicate areas for improvement of the DASH as an upper limb measure for acute stroke. Findings, similar to those identified in multiple sclerosis, highlight the need for scales to have strong conceptual underpinnings, with their development and modification guided by sophisticated psychometric methods.

Factors affecting functional recovery after surgery and hand therapy in patients with Dupuytren's disease

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

The evidence of the relationship between functional recovery and impairment after surgery and hand therapy are inconsistent.

PURPOSE OF THE STUDY

To explore factors that were most related to functional recovery as measured by DASH in patients with Dupuytren's disease.

METHODS

Eighty-one patients undergoing surgery and hand therapy were consecutively recruited. Functional recovery was measured by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Explanatory variables: range of motion of the finger joints, five questions regarding safety and social issues of hand function, and health-related quality of life (Euroqol).

RESULTS

The three variables "need to take special precautions", "avoid using the hand in social context", and health-related quality of life (EQ-5D index) explained 62.1% of the variance in DASH, where the first variable had the greatest relative effect.

DISCUSSION

Safety and social issues of hand function and quality of life had an evident association with functional recovery.

LEVEL OF EVIDENCE

IV.

Prevalence of and Factors Associated With Major Depression in Patients With Upper Extremity Conditions

PURPOSE

To determine the prevalence of an estimated diagnosis of major depression in patients with upper extremity conditions and factors that help identify patients who might benefit from psychological treatment.

METHODS

In this observational cross-sectional study, 190 patients completed questionnaires measuring symptoms of depression with the Patient Health Questionnaire, upper extremity disability with the Patient-Reported Outcomes Measurement Information System Upper Extremity, pain interference with the Patient-Reported Outcomes Measurement Information System Pain Interference, and health anxiety with the Short Health Anxiety Inventory.

RESULTS

The estimated prevalence of an estimated diagnosis of major depression (Patient Health Questionnaire 9 ≥ 10) among this group of patients was 12%. Having multiple pain conditions, a history of depression, and greater limitation from pain for daily activities were independently associated with an estimated diagnosis of major depression.

CONCLUSIONS

The finding that 1 in 8 patients presenting to a hand surgeon have untreated or undertreated symptoms of depression sufficient to qualify for an estimated diagnosis of major depression emphasizes the importance of assessing for depression at all levels of care.