Recovery-related anxiety and disability following upper limb injury: the importance of context

Comparison of short-term outcomes between people with and without a pre-morbid mental health diagnosis following surgery for traumatic hand injury: a prospective longitudinal study of a multicultural cohort

BACKGROUND

Following traumatic hand injury, few studies have compared outcomes between people with and without a pre-morbid mental health diagnosis. This study aimed to compare sub-acute outcomes in a multicultural patient cohort with surgically managed traumatic hand injury with and without a pre-morbid mental health diagnosis.

METHODS

A prospective, observational cohort study of people with traumatic hand injury presenting pre- surgically to a high-volume hand injury centre in a region of cultural and language diversity was conducted. Participants were assessed face-to-face (baseline) then via telephone (3-months post-surgery) and categorized according to a pre-morbid medically diagnosed mental health diagnosis. Baseline and follow-up assessments included global mental health, and the EuroQol (EQ) 'Health Today' analogue scale (0-100) and health domains. Return-to-work status, complications/symptomatic complaints, and hand function (QuickDASH) were also collected at follow-up. Adjusted analyses-accounting for covariates including cultural identity-were conducted to determine whether 3-month outcomes were associated with a pre-morbid mental health diagnosis.

RESULTS

From 405 eligible patients, 386 were enrolled (76% male, mean age 38.9 (standard deviation 15.6)); 57% self-identified as Australian and 22% had a pre-morbid mental health diagnosis. Common injuries regardless of pre-morbid mental health diagnosis were skin (40%), tendon (17%) and bone (17%) injuries. None were complex mutilating injuries. Seventy-eight per cent of the cohort was followed-up. In adjusted analyses, a pre-morbid mental health diagnosis was associated with lower odds for reporting 'good or better' global mental health (Odds Ratio (OR) 0.23 (95% Confidence Interval (CI) 0.18, 0.47), p < 0.001), 'no' anxiety or depression (OR 0.21 (0.11, 0.40), p < 0.001) and no pain (OR 0.56 (0.31, 0.98), p = 0.04)(EQ domains), and worse EQ 'Health Today' (10 points on average (95%CI -14.9, -5.1, p < 0.001). QuickDASH scores, rates of complications/symptomatic complaints and return-to-work profiles were similar.

CONCLUSIONS

Despite reporting worse mental and health-related quality-of-life outcomes post-surgery, people with a pre-morbid mental health diagnosis regardless of cultural identity experienced similar clinical and return-to-work outcomes. Future research assessing the value of screening for pre-morbid mental health conditions on post-surgical outcomes is required and should include people with more complex hand injuries.

Understanding individuals' perspectives and experiences of recovery following a proximal humerus fracture: an interpretive description

PURPOSE

Proximal humerus fractures are common in older adults and optimizing their outcomes following this injury can be challenging. This study explored recovery from the perspective of individuals who experience proximal humerus fracture.

MATERIALS AND METHODS

We conducted in-depth semi-structured interviews (n = 14) with participants (aged 45 and over) recruited from a hand clinic in London, Ontario using a purposive sampling technique. The exploratory interviews were audio-recorded, transcribed, and analyzed using interpretive description approach.

RESULTS

Four themes emerged from the narratives of individuals: challenges of day-to-day activities, coping as you go, recapturing valued life roles, and support matters.

CONCLUSIONS

Recovery after PHF seems relative to contexts and manifests within numerous scenarios. Based on individuals' narratives, the context produces a mosaic that contributes to unique recovery perception and experience. Awareness of the context emphasizes the complexity inherent in recovery and may guide healthcare professionals' efforts toward care for their patients.IMPLICATIONS FOR REHABILITATIONIndividuals with proximal humerus fracture experience recovery as a personal and dynamic process occurring in their diverse contexts.Healthcare professionals need to recognize the significant impact of context on individuals' physical, emotional, and social life following proximal humerus fracture (PHF).A multidisciplinary treatment plan might be desirable where people with PHF and health care professionals collaborate as a whole.Building a multidisciplinary health team including healthcare professionals, peer support, and case management may remove some barriers and facilitate the transition to recovery.

Prediction of disability in trigger finger: a cross-sectional and longitudinal study

The aim of this prospective study of 55 patients was to analyse the cross-sectional and longitudinal relationship between disability and physical and psychological variables after conservative treatment of trigger finger and to determine the predictive factors for the post-treatment disability score and change in disability score. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand questionnaire. Potential predictive factors included pain, number of triggering events, depression, anxiety and kinesiophobia. Disability correlated strongly with anxiety, moderately with pain and depression and weakly with triggering and kinesiophobia. The change in depression score correlated significantly with the change in disability score. Post-treatment pain and anxiety scores accounted for 47% of the explained variance in disability score. Improvement in depression after treatment accounted for 18% of the explained variance in disability change score. Psychological variables appear to be potential predictors of disability.Level of evidence: IV.

The use of myoelectric prosthesis in a sample of veterans with unilateral upper extremity amputation: prosthesis satisfaction and quality of life

AIMS

To determine the relationship between clinic and prosthesis-related characteristics and psychosocial adjustment, activity restriction, satisfaction with the prosthesis and quality of life in myoelectric prosthesis users with upper limb amputation.

METHODS

Thirty patients with myoelectric prosthesis users with upper limb amputation took part in this study. The patients' demographic and clinical information were recorded. Psychosocial adjustment, activity restriction and satisfaction with the prosthesis were assessed with Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R). Short-Form 36 (SF-36) was used for the quality of life.

RESULTS

TAPES-R activity restriction score was significantly higher in patients with transhumeral or elbow disarticulation and with concomitant lower limb amputation (p = 0.009, p = 0.037, respectively). TAPES-R psychosocial adjustment subparameter score had significantly moderate correlation with daily prosthesis wearing time (p = 0.019 r = 0.425). A significant negative correlation was found between age at the time of the injury and SF-36 role limitation due to physical problem (p = 0.028 r = - 0.401).

CONCLUSIONS

Clarifying the factors related to psychosocial adjustment, activity restriction, prosthesis satisfaction and quality of life in individuals with upper extremity amputation and producing interventions/approaches that support patients' life are meaningful and important steps.

CLINICAL TRIAL REGISTER

E2-22-1416.

Misperception of Disease Onset in People with Gradual-Onset Disease of the Upper Extremity

BACKGROUND

Misperception that an established, gradual-onset disease such as osteoarthritis started when the symptoms were first noticed might lead to testing and treatment choices that are inconsistent with what matters most to a patient. In the present study, the primary null hypothesis was that there are no factors associated with patient-reported symptom duration (in months). The secondary null hypotheses were that there are no factors independently associated with (1) a sudden versus gradual perception of disease onset, (2) an event or injury-related versus age-related perceived cause of disease onset, and (3) the magnitude of physical limitations.

METHODS

In this cross-sectional study, 121 patients with an atraumatic, established, gradual-onset condition of the upper extremity completed a demographic questionnaire, measures of mental health (symptoms of depression and anxiety, worst-case thinking, and self-efficacy [the ability to adapt and continue with daily activity] when in pain), measurement of the magnitude of upper extremity-specific limitations, and questions about the perceived course and cause of the disease.

RESULTS

The median patient-reported symptom duration was 12 months (interquartile range, 3 to 36 months). Twenty-two patients (18%) perceived their disease as new, and 29 patients (24%) believed that the condition was related to ≥1 event (injury) rather than being time and age-related. In multivariable analysis, patients with Medicare insurance were independently associated with longer reported symptom duration (in months). Greater self-efficacy was associated with longer symptom duration in bivariate, but not multivariable, analysis. No factors were independently associated with a sudden versus gradual onset of symptoms. Hispanic ethnicity and federal, county, or no insurance were independently associated with the perception that the problem was caused by an injury or event.

CONCLUSIONS

Approximately 1 in 5 patients misperceived new symptoms as representing a new disease, often as a type of injury. Misperception of the pathology as new had a limited association with unhealthy thoughts and is likely generally responsive to reorientation. We speculate that gentle, strategic reorientation of misperception can protect patients from choices inconsistent with their values.

The relationship between impulsivity and anxiety and recurrent metacarpal fractures due to punch injury

PURPOSE

The study aimed to determine the relationship between impulsivity and anxiety and recurrent metacarpal fractures (RMF) due to punching injury.

METHODS

Consecutive 368 patients (301 men and 67 women) with metacarpal fracture who met the inclusion criteria and 214 healthy controls were included in the study. The study group was divided into two as the first metacarpal fracture (FMF) (245 patients) and RMF (123 patients). The control group consisted of sex- and age-matched 214 healthy participants (175 men and 39 women). Beck anxiety inventory (BAI), Barratt impulsiveness scale (BIS 11), and Quick DASH scores were the assessment of the patients in the sixth month of treatment. The groups were compared in terms of demographic features (including education status, marital status, work status, and level of income), fracture side, fracture location, dominant hand, treatment, anxiety, impulsivity, and functional results.

RESULTS

In the RMF, BIS 11, BAI, and Quick DASH scores were significantly higher than the FMF and the healthy controls (p = 0.001 and p = 0.001, respectively). The patients with RMF have higher impulsivity and anxiety, worse short-term functional outcomes, and lower level of income and education status compared with healthy controls and FMF.

CONCLUSION

Anxiety and impulsivity are higher in patients with RMF. It adversely affects the clinical outcome after the treatment. Psychiatric consultation is an important step for especially intentional RMF patients to prevent recurrent hand injuries and metacarpal fractures and to improve clinical outcomes associated with these injuries.

The assessment of psychological factors on upper extremity disability: A scoping review

INTRODUCTION

The primary purpose of this scoping review was to describe the nature and extent of the published research that assesses the relationship between psychological features and patient-reported outcome following surgery or rehabilitation of upper extremity disease or injury.

METHODS

Twenty-two included studies were examined for quantitative study design, outcome measure, inclusion/exclusion criteria, follow-up and recruitment strategy. Patient population and psychological assessment tools were examined for validity.

RESULTS

Twenty-two studies met the inclusion criteria for this study. Only 7 of the 22 studies were longitudinal and the rest were cross sectional studies. Depression was the most common psychological status of interest and was included in 17 studies. Pain catastrophizing was the psychological status of interest in 5 of the studies. Four studies considered anxiety, 3 considered pain anxiety, 3 considered distress, 2 considered coping, 2 considered catastrophic thinking, and 2 considered fear avoidance beliefs.

DISCUSSION

The majority of studies in this review were cross-sectional studies. Cross-sectional studies may not provide conclusive information about cause-and-effect relationships. This review encourages clinicians to be mindful of the psychological implications found in rehabilitation of individuals with upper extremity disease or injury along with being cognizant of choosing appropriate measurement tools that best represent each patient's characteristics and diagnoses.

CONCLUSIONS

The nature of the research addressing psychological factors affecting outcomes after hand injury focus on negative traits and have limited strength to suggest causation as most have used cross-sectional designs. Stronger longitudinal designs and consideration of positive traits are needed in future studies.

Psychological distress among persons with upper extremity limb loss

OBJECTIVE

We examined predictors of clinically significant levels of psychological distress among individuals with upper limb loss (ULL).

DESIGN

A multisite, cross-sectional study completed at six prosthetic rehabilitation centres throughout the United States.

METHODS

Oral administration of a brief assessment battery to 307 participants with ULL including demographic variables, injury information, screening instruments for PTSD and depression, pain interference, and activity restriction measures. Hierarchical multinomial logit models were conducted. Outcome groups were created using recommended cut-off scores on brief screening measures of depression and PTSD. Final models were assessed including relative risk ratios and marginal effects.

RESULTS

Over half of the sample screened positive for depression, PTSD, or both. Eight individuals exceeded the recommended cut-off score indicative of PTSD only (2.6%), and 106 participants (34.5%) screened positive for depression only. Moreover, 64 participants (20.8%) reported co-occurring PTSD and depression. Subsequent models revealed women and ethnic minority participants were more likely to have clinically significant levels of depression and PTSD. Greater restriction in activity and increased pain interference also predicted psychological distress.

CONCLUSIONS

These findings indicate a significant number of individuals with ULL experience clinically significant levels of psychological distress, and routine clinical assessment of depression and PTSD is warranted. Women and individuals from ethnic minorities may be particularly at risk, regardless of the severity and cause of ULL. Restrictions in preferred and goal-directed activities and persistent pain are also contributing factors. Psychological interventions that address these issues are indicated. Statement of contribution What is already known on this subject? Research investigating psychological reactions and adjustment after limb loss has primarily focused on lower limb loss. Little research has investigated psychological adjustment or distress following upper extremity loss. Lower extremity limb loss is more likely to be from a disease process while upper extremity limb loss is more likely to be due to traumatic injuries. Upper extremity limb loss possesses a qualitatively different experience as upper limb amputation is more readily apparent to others, impacts activities of daily living, and limits instrumental function in social and non-verbal communication. What does this study add? A significant percentage of individuals with upper limb loss report significant levels of depression, PTSD, and mixed depression and PTSD. Moreover, women and minority clients were more likely to report clinically significant levels of depression and mixed PTSD and depression. Activity restriction and pain interference's contributions in the final model helped to elucidate the clinical picture of psychological distress for persons with upper extremity limb loss. Greater activity restriction and limitations from pain interference increased the likelihood of reporting clinically significant levels of psychological distress.

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.

Patient-Reported Outcomes Measurement Information System Outcome Measures and Mental Health in Orthopaedic Trauma Patients During Early Recovery

OBJECTIVES

This study explored the relationships between negative affective states (depression and anxiety), physical/functional status, and emotional well-being during early treatment and later in recovery after orthopaedic trauma injury.

DESIGN

This was a secondary observational analysis from a randomized controlled study performed at a Level-1 trauma center.

PATIENTS

Patients with orthopaedic trauma (N = 101; 43.5 ± 16.4 years, 40.6% women) were followed from acute care to week 12 postdischarge.

MAIN OUTCOME MEASURES

Patient-reported outcomes measurement information system measures of Physical Function, Psychosocial Illness Impact-Positive and Satisfaction with Social Roles and Activities and the Beck Depression Inventory-II and the State-Trait Anxiety Inventory were administered during acute care and at weeks 2, 6, and 12. Secondary measures included hospital length of stay, adverse readmissions, injury severity, and surgery number.

RESULTS

At week 12, 20.9% and 35.3% of patients reported moderate-to-severe depression (Beck Depression Inventory-II score ≥20 points) and anxiety (State-Anxiety score ≥40 points), respectively. Depressed patients had greater length of stay, complex injuries, and more readmissions than those without. The study sample improved patient-reported outcomes measurement information system T-scores for Physical Function and Satisfaction with Social Roles and Activities by 40% and 22.8%, respectively (P < 0.0001), by week 12. Anxiety attenuated improvements in physical function. Both anxiety and depression were associated with lower Psychosocial Illness Impact-Positive scores by week 12.

CONCLUSIONS

Although significant improvements in patient-reported physical function and satisfaction scores occurred in all patients, patients with depression or anxiety likely require additional psychosocial support and resources during acute care to improve overall physical and emotional recovery after trauma.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Systematic review: Predicting adverse psychological outcomes after hand trauma

STUDY DESIGN

Systematic review.

INTRODUCTION AND PURPOSE OF THE STUDY

After traumatic hand injury, extensive physical and psychological adaptation is required following surgical reconstruction. Recovery from injury can understandably be emotionally challenging, which may result in impaired quality of life and delayed physical recovery. However, the evidence base for identifying high-risk patients is limited.

METHODS

A PROSPERO-registered literature search of MEDLINE (1946-present), EMBASE (1980-present), PsychInfo, and CINAHL electronic databases identified 5156 results for studies reporting psychological outcomes after acute hand trauma. Subsequent review and selection by 2 independent reviewers identified 19 studies for inclusion. These were poor quality level 2 prognostic studies, cross sectional or cohort in design, and varied widely in methodology, sample sizes, diagnostic methods, and cutoff values used to identify psychological symptoms. Data regarding symptoms, predisposing factors, and questionnaires used to identify them were extracted and analyzed.

RESULTS

Patients with amputations or a tendency to catastrophize suffered highest pain ratings. Persisting symptom presence at 3 months was the best predictor of chronicity. Many different questionnaires were used for symptom detection, but none had been specifically validated in a hand trauma population of patients. Few studies assessed the ability of selection tools to predict patients at high risk of developing adverse psychological outcomes.

DISCUSSION AND CONCLUSION

Despite a limited evidence base, screening at 3 months may detect post-traumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes.

LEVEL OF EVIDENCE

Level 4.

Long-term outcome in 324 polytrauma patients: what factors are associated with posttraumatic stress disorder and depressive disorder symptoms?

Background

Physical impairment is well-known to last for many years after a severe injury, and there is a high impact on the quality of the survivor’s life. The purpose of this study was to examine if this is also true for psychological impairment with symptoms of posttraumatic stress disorder or depression after polytrauma.

Design

Retrospective cohort outcome study.

Setting

Level I trauma centre.

Population

637 polytrauma trauma patients who were treated at our Level I trauma centre between 1973 and 1990. Minimum follow-up was 10 years after the injury.

Methods

Patients were asked to fill in a questionnaire, including parts of the Posttraumatic Stress Diagnostic Scale, the Impact of Event Scale-Revised and the German Hospital Anxiety and Depression Scale, to evaluate mental health. Clinical outcome was assessed before by standardised scores.

Results

Three hundred and twenty-four questionnaires were evaluated. One hundred and forty-nine (45.9%) patients presented with symptoms of mental impairment. Quality of life was significantly higher in the mentally healthy group, while the impaired group achieved a lower rehabilitation status.

Conclusions

Mental impairment can be found in multiple trauma victims, even after 10 years or more. Treating physicians should not only focus on early physical rehabilitation but also focus on early mental rehabilitation to prevent long-term problems in both physical and mental disability.