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

Psychosocial factors affecting variation in patient-reported outcomes after elbow fractures

BACKGROUND

The purpose of this study was to identify factors associated with limitations in function measured by patient-reported outcome measures (PROMs) 6-9 months after elbow fractures in adults from a range of demographic, injury, psychological, and social variables measured within a week and 2-4 weeks after injury.

METHODS

We enrolled 191 adult patients sustaining an isolated elbow fracture and invited them to complete PROMs at their initial visit to the orthopedic outpatient clinic (within a maximum of 1 week after fracture), between 2 and 4 weeks, and between 6 and 9 months after injury; 183 patients completed the final assessment. Bivariate analysis was performed, followed by multivariable regression analysis accounting for multicollinearity. This was evaluated using partial R², correlation matrices, and variable inflation factor assessment.

RESULTS

There was a correlation between multiple variables within a week of injury and 2-4 weeks after injury with PROMs 6-9 months after injury in bivariate analysis. Kinesiophobia measured within a week of injury and self-efficacy measured at 2-4 weeks were the strongest predictors of limitations 6-9 months after injury in multivariable regression. Regression models accounted for substantial variance in all PROMs at both time points.

CONCLUSIONS

Developing effective coping strategies to overcome fears related to movement and reinjury and finding ways of persevering with activity despite pain within a month of injury may enhance recovery after elbow fractures. Heightened fears around movement and suboptimal coping ability are modifiable using evidence-based behavioral treatments.

Factors associated with the magnitude of limitations during recovery from a fracture of the proximal humerus

Aims

The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury.

Patients and Methods

We enrolled 177 adult patients who sustained an isolated proximal humeral fracture into the study and invited them to complete PROMs at their initial outpatient visit within one week of injury, between two and four weeks, and between six to nine months after injury. There were 128 women and 49 men; the mean age was 66 years (sd 16; 18 to 95). In all, 173 patients completed the final assessment. Bivariate analysis was performed followed by multivariable regression analysis accounting for multicollinearity using partial R2, correlation matrices, and variable inflation factor.

Results

Many variables within a week of injury and between two and four weeks after injury correlated with six- to nine-month PROMs in bivariate analysis. Kinesiophobia measured within a week of injury (Tampa Scale for Kinesiophobia-11: partial R2 = 0.14; p = 0.000) and self-efficacy measured between two and four weeks (Pain Self-efficacy Questionnaire-2: partial R2 = 0.266; p < 0.001) were the strongest predictors of limitations (measured by Patient Reported Outcome Measurement Information System Upper Extremity Physical Function Computer Adaptive Test (PROMIS UE)) at six to nine months in multivariable analysis. Similar findings were observed with other types of PROM. Regression models accounted for a substantial amount of variance in all PROMs at both timepoints (e.g. 66% of the overall variance within one week, and 70% within two to four weeks for PROMIS UE at six to nine months).

Conclusion

Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy (developing resilience and more effective coping strategies) within a month. Such factors are modifiable using enhanced communication skills and cognitive behavioural treatments. These findings could be a catalyst for the routine assessment and treatment of psychological and social factors in the management of patients with fractures. Cite this article: Bone Joint J 2019;101-B:715–723.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Defining Quality in Hand Surgery From the Patient's Perspective: A Qualitative Analysis

PURPOSE

Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process.

METHODS

A steering committee (n = 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective.

RESULTS

We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery.

CONCLUSIONS

Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development.

CLINICAL RELEVANCE

Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.

What Factors Are Associated With Outcomes Scores After Surgical Treatment Of Ankle Fractures With a Posterior Malleolar Fragment?

BACKGROUND

Psychosocial factors, such as depression and catastrophic thinking, might account for more disability after various orthopaedic trauma pathologies than range of motion and other impairments. However, little is known about the influence of psychosocial aspects of illness on long-term symptoms and limitations of patients with rotational-type ankle fractures, including a posterior malleolar fragment. Knowledge of the psychosocial factors associated with long-term outcome after operative treatment of trimalleolar ankle fractures might improve recovery.

QUESTIONS/PURPOSES

(1) Which factors related to patient demographics, physical exam, diagnosis, or psychological well-being (in particular, depression), if any, are associated with better or worse scores on validated lower-extremity outcomes instruments after surgical treatment for rotational ankle fractures (including a posterior malleolar fragment) at long-term followup?

METHODS

Between 1974 and 2002, 423 patients underwent open reduction internal fixation for rotational ankle fractures with posterior malleolar fragments according to the basic principles of the AO (Arbeitsgemeinshaft für Osteosynthesfragen). Minimum followup for inclusion here was 10 years (range, 12.5-39.4 years). When posterior malleolar fragments involved more than 25% of the articular surface as assessed on plain lateral radiographs, the fracture was generally fixed with AP or posterior-anterior (PA) screws. Of those treated surgically during the period in question, 319 were lost to followup, had too much missing data to include, or declined to participate in this study (or could not because of reasons of mental illness) (68%), leaving 104 (32%) for analysis in this retrospective study. Independent observers not involved in patient care measured disability using the patient-based Foot and Ankle Ability Measure questionnaire and using the subscale Activities in Daily Living (ADL) and pain score of the Foot and Ankle Outcome Score. General physical and mental health status was evaluated using the SF-36. Depressive symptoms were measured with the Center for Epidemiologic Studies-Depression scale score (range, 0-60 points). A score above 16 indicated a depressive disorder. Misinterpretation or overinterpretation of nociception was measured with the Pain Catastrophizing Scale score. Scores above 13.9 were considered abnormal. Statistical analyses included uni- and multivariate regression analysis. In general, patients in this series reported good to excellent outcomes; the mean ± SD scores were 91 ± 15 for Foot and Ankle Ability Measure, 93 ± 16 for Foot and Ankle Outcome Score (ADL), 91 ± 15 for Foot and Ankle Outcome Score (pain), 49 ± 9 for SF-36 mental component score, and 52 ± 9 for SF-36 physical component score.

RESULTS

Implant removal (β = -8.199, p < 0.01) was associated with worse Foot and Ankle Ability Measure scores. Better flexion/extension arc (β = 0.445, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.527, p < 0.01) were associated with better Foot and Ankle Ability Measure scores. Osteoarthritis (β = -4.823, p < 0.01) was associated with worse Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (β = 0.454, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.596, p < 0.01) were associated with better Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (β = -0.431, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.557, p < 0.01) were associated with better Foot and Ankle Outcome Score (ADL) scores. Finally, we found that a better inversion/eversion arc (β = 0.122, p = 0.024) was associated with better SF-36 physical component score and that a lower Center for Epidemiologic Studies-Depression score (β = -0.567, p < 0.01) was associated with better SF-36 mental component score.

CONCLUSIONS

Psychological aspects of recovery from musculoskeletal injury merit greater attention, perhaps even over objective, unmodifiable predictors. A mean of 24 years after surgical treatment of ankle fractures with a posterior malleolar fragment, patient-reported outcome measures have little to do with pathophysiology; they mostly reflect impairment and depression symptoms. Further research is needed to determine whether early indentification and treatment of at-risk patients based on psychosocial factors can improve long-term outcomes.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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.

Can pain catastrophizing be changed in surgical patients? A scoping review

Background

Catastrophizing, a coping style characterized by an exaggerated negative affect when experiencing or anticipating pain, is an important factor that adversely affects surgical outcomes. Various interventions have been attempted with the goal of reducing catastrophizing and, by extension, improving treatment outcomes. We performed a systematic review to determine whether catastrophizing can be altered in surgical patients and to present evidence for interventions aimed at reducing catastrophizing in this population.

Methods

Using a scoping design, we performed a systematic search of MEDLINE and Embase. Studies reporting original research measuring catastrophizing, before and after an intervention, on the Pain Catastrophizing Scale (PCS) or Coping Strategies Questionnaire (CSQ) were selected. Studies were assessed for quality, the nature of the intervention and the magnitude of the effect observed.

Results

We identified 47 studies that measured the change in catastrophizing score following a broad range of interventions in surgical patients, including surgery, patient education, physiotherapy, cognitive behavioural therapy, psychologist-directed therapy, nursing-directed therapy and pharmacological treatments. The mean change in catastrophizing score as assessed with the PCS ranged from 0 to –19, and that with the CSQ, from +0.07 to –13. Clinically important changes in catastrophizing were observed in 7 studies (15%).

Conclusion

Catastrophizing was observed to be modifiable with an intervention in a variety of surgical patient populations. Some interventions produced greater reductions than others, which will help direct future research in the improvement of surgical outcomes.

Pre-injury depression and anxiety in patients with orthopedic trauma and their treatment

PURPOSE

Depressive symptoms have a known negative impact on outcomes following musculoskeletal injury. This study determined the pre-injury prevalence of psychiatric diagnoses of depression and anxiety, medication lapses and psychiatric consult services among patients admitted for orthopaedic trauma.

METHODS

This is a retrospective study of data from our Level-1 trauma center. Patients admitted to the orthopaedic trauma service during 2010-2015 were included (N = 4053). Demographics, Injury Severity Scores (ISS), mental health diagnoses, psychotropic medications, medication type and delay, psychiatric consultation use, intensive care unit (ICU) stay and total hospital length of stay (LOS) were abstracted from medical records and the institutional trauma registry.

RESULTS

The 12-month prevalence of a major depressive episode is 6.6%-8.6% in adults in the United States. In our database, only 152/4053 (3.8%) of the patients had documented medical history of depression (80%) or anxiety (30%), and these patients had a 32% longer LOS (p < 0.016). Nearly two-thirds of patients who used psychotropic medications prior to injury experienced a delay in receiving these medications in the hospital (median = 1.0 day, range 0-14 days). Sixteen percent of patients also received a new psychotropic medication while hospitalized: an antipsychotic (8/16 patients, to treat delirium), an anxiolytic (3/16 patients for acute anxiety), or an antidepressant (1/16). Among patients with depression or anxiety, 16.7% received a psychiatric consult. Patients with psychiatric consults had higher ISS, were more likely to have longer ICU LOS and had longer hospital LOS than those without consults (all p < 0.05).

CONCLUSION

The prevalence of depression and anxiety is grossly under-reported in our registry compared to national prevalence data. Patients with pre-existing disease had longer LOS and a higher rate of extended ICU care. Further studies are needed to characterize the true prevalence of disease in this patient population and its effect on patient outcomes after traumatic orthopaedic injury.

A Hybrid Web-Based and In-Person Self-Management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma: Feasibility and Acceptability of iPACT-E-Trauma

Background

A transition from acute to chronic pain frequently occurs after major lower extremity trauma. While the risk factors for developing chronic pain in this population have been extensively studied, research findings on interventions aiming to prevent chronic pain in the trauma context are scarce. Therefore, we developed a hybrid, Web-based and in-person, self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma).

Objective

This study aimed to assess the feasibility and acceptability of iPACT-E-Trauma.

Methods

Using a descriptive design, the intervention was initiated at a supra-regional level-1 trauma center. Twenty-eight patients ≥18 years old with major lower extremity trauma, presenting with moderate to high pain intensity 24 hours post-injury were recruited. Feasibility assessment was two-fold: 1) whether the intervention components could be provided as planned to ≥80% of participants and 2) whether ≥80% of participants could complete the intervention. The rates for both these variables were calculated. The E-Health Acceptability Questionnaire and the Treatment Acceptability and Preference Questionnaire were used to assess acceptability. Mean scores were computed to determine the intervention’s acceptability.

Results

More than 80% of participants received the session components relevant to their condition. However, the Web pages for session 2, on the analgesics prescribed, were accessed by 71% of participants. Most sessions were delivered according to the established timeline for ≥80% of participants. Session 3 and in-person coaching meetings had to be provider earlier for ≥35% of participants. Session duration was 30 minutes or less on average, as initially planned. More than 80% of participants attended sessions and <20% did not apply self-management behaviors relevant to their condition, with the exception of deep breathing relaxation exercises which was not applied by 40% of them. Web and in-person sessions were assessed as very acceptable (mean scores ≥3 on a 0 to 4 descriptive scale) across nearly all acceptability attributes.

Conclusions

Findings showed that the iPACT-E-Trauma intervention is feasible and was perceived as highly acceptable by participants. Further tailoring iPACT-E-Trauma to patient needs, providing more training time for relaxation techniques, and modifying the Web platform to improve its convenience could enhance the feasibility and acceptability of the intervention.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6ynibjPHa)

Complex Regional Pain Syndrome After Distal Radius Fracture Is Uncommon and Is Often Associated With Fibromyalgia

BACKGROUND

Complex regional pain syndrome (CRPS) is frequently diagnosed in patients recovering from surgery or injury. The symptoms and signs included in consensus diagnostic criteria for CRPS are expected after injury. Categorizing symptoms and signs that occur on a continuum as disproportionate or not is subjective and prone to bias. Psychiatrists and psychologists do not diagnose CRPS and instead measure and treat anxiety and catastrophic thinking on its continuum. Given the expected variation in subjective diagnoses such as CRPS, this study addresses factors associated with use of this diagnosis and how it influences care.

QUESTIONS/PURPOSES

(1) Among patients recovering from fracture of the distal radius, what factors are associated with the diagnosis of CRPS? (2) Are patients diagnosed with CRPS after distal radius fractures, as opposed to those without CRPS, more likely to have a bone scan, stellate ganglion block, therapy, or subsequent surgery?

METHODS

Using the Truven database, we identified 59,765 patients treated for a distal radius fracture from 2012 to 2014, of whom 114 (0.19%) were diagnosed with CRPS. The Truven Health MarketScan database is an administrative claims data set of commercially insured patients and this analysis only included patients with complete enrollment from 2012 through 2014. Bivariate analyses sought differences between patients diagnosed with and patients not diagnosed with CRPS. All factors with p < 0.05 were included in a multivariable logistic regression model.

RESULTS

The covariates older age (odds ratio [OR], 1.029; 95% confidence interval [CI], 1.011-1.048; p = 0.002), gender (women at greater risk, OR, 3.86; CI, 1.99-7.49; p < 0.001), concomitant fracture of the distal ulna (OR, 1.54; CI, 1.05-2.23; p = 0.029), open fracture (OR, 0.414; CI, 0.192-0.895; p = 0.025), and comorbid fibromyalgia (OR, 16.0; CI, 4.92-51.8; p < 0.001) were independently associated with a diagnosis of CRPS among patients recovering from a fracture of the distal radius. Patients diagnosed with CRPS are more likely than other patients with a distal radius fracture to have had a bone scan (OR, 66.0; CI, 8.19-532; p < 0.001), physical or occupational therapy (OR, 3.89; CI, 2.68-5.67; p < 0.001), and subsequent wrist surgery (OR, 2.52; CI, 1.65-3.84; p < 0.001). No one had a stellate ganglion injection.

CONCLUSIONS

We found that a coded diagnosis of CPRS is uncommonly applied to patients on the higher range of pain, stiffness, and limitations after fracture of the distal radius-most commonly in women and in association with another nonspecific, objectively unverifiable diagnosis (fibromyalgia)-and that this label may lead to more testing and invasive treatment. Future research should address the utility and value of diagnoses that create subjective categories for aspects of human illness that occur on a continuum.

LEVEL OF EVIDENCE

Level III, prognostic study.

Is Use of a Psychological Workbook Associated With Improved Disabilities of the Arm, Shoulder and Hand Scores in Patients With Distal Radius Fracture?

BACKGROUND

Symptom intensity and magnitude of limitations correlate with stress, distress, and less effective coping strategies. It is unclear if interventions to target these factors can be used to improve outcomes after distal radius fracture in either the short- or longer term.

QUESTIONS/PURPOSES

(1) Are there any factors (including the use of a workbook aimed at optimizing psychological response to injury, demographic, radiographic, medical, or psychosocial) associated with improved Disabilities of the Arm, Shoulder and Hand (DASH) and Numerical Rating Scale pain (NRS pain) scores at 6 weeks after management of distal radius fracture? (2) Are any of these factors associated with improved DASH and NRS pain scores at 6 months after management of distal radius fracture?

METHODS

We conducted a double-blind randomized controlled trial comparing a workbook designed to optimize rehabilitation by improving psychological response to injury using recognized psychological techniques (the LEARN technique and goal setting) versus a workbook containing details of stretching exercises in the otherwise routine management of distal radius fracture. Patients older than 18 years of age with an isolated distal radius fracture were recruited within 3 weeks of injury from a single academic teaching hospital between March and August 2016. During recruitment, 191 patients who met the inclusion criteria were approached; 52 (27%) declined participation and 139 were enrolled. Eight patients (6%) were lost to followup by 6 weeks. The remaining cohort of 129 patients was included in the analysis. DASH scores and NRS pain scores were recorded at 6 weeks and 6 months after injury. Multivariable regression analysis was used to identify factors associated with outcome scores.

RESULTS

At 6 weeks after distal radius fracture, when compared with an information-only workbook, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 38 [range, 21-48]; control DASH: 35 [range, 21-53]; difference of medians: 3; p = 0.949) nor NRS pain scores (workbook NRS: 3 [range, 1-5]; control NRS: 2 [range, 1-4]; difference of medians: 1; p = 0.128). Improved DASH scores were associated with less radial shortening (β = 0.2, p = 0.009), less dorsal tilt (β = 0.2, p = 0.035), and nonoperative treatment (β = 0.2, p = 0.027). Improved NRS pain scores were associated with nonoperative treatment (β = 0.2, p = 0.021) and no posttraumatic stress disorder (PTSD) (β = 0.2, p = 0.046). At 6 months, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 11 [range, 5-28]; control DASH: 11 [range, 3-20]; difference of medians: 0; p = 0.367) nor NRS pain scores (workbook NRS: 1 [range, 0-2]; control NRS: 1 [range, 0-2]; difference of medians: 0; p = 0.704). Improved DASH score at 6 months was associated with having fewer medical comorbidities (β = 0.3, p < 0.001) and lower enrollment PTSD (β = 0.3, p < 0.011). Lower NRS pain scores at 6 months were associated with having fewer medical comorbidities (β = 0.2, p = 0.045), lower enrollment PTSD (β = 0.3, p = 0.008), and lower enrollment Tampa Scale for Kinesiophobia (β = 0.2, p = 0.042).

CONCLUSIONS

Our study demonstrates that there is no benefit from the untargeted use of a psychological workbook based on the LEARN approach and goal-setting strategies in patients with distal radius fracture. Future research should investigate if there is a subgroup of patients with a negative psychological response to injury that benefits from psychological intervention and, if so, how best to identify these patients and intervene.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials

BACKGROUND

Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes.

MATERIALS AND METHODS

We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias.

RESULTS

Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2-3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding.

CONCLUSION

This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP.

Volar Capsular Release After Distal Radius Fractures

PURPOSE

Loss of full wrist range of motion is common after treatment of distal radius fractures. Loss of wrist extension limiting functional activities, although uncommon, can occur after volar plating of distal radius fractures. Unlike other joints in which capsular release is a common form of treatment for stiffness, this has been approached with caution in the wrist owing to concerns for carpal instability. We tested the null hypothesis that hardware removal and open volar capsular release would not lead to improved upper extremity-specific patient-reported outcome (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).

METHODS

We conducted a retrospective chart review of patients who underwent a tenolysis of the flexor carpi radialis tendon, removal of hardware, and subperiosteal release of the volar capsule (extrinsic ligaments). The primary outcome measure was patient-reported outcome on the DASH. Secondary outcomes included wrist flexion, extension, pronation, and supination, visual analog scale for pain, and radiographs/fluoroscopy for ulnocarpal translocation.

RESULTS

Eleven patients were treated with a mean follow-up of 4.5 years. Mean DASH scores improved after surgery. Mean wrist flexion, wrist extension, pronation, and supination improved after surgery. Mean visual analog scale scores did not change. The radiocarpal relationship on radiographs/fluoroscopy was normal.

CONCLUSIONS

Open volar capsular release to regain wrist extension after treatment of distal radius fractures with volar locking plates is safe and effective. Patients regain wrist extension in addition to improved DASH scores. There were no radiographic/fluoroscopic or clinical signs of ulnocarpal translocation after release of the volar extrinsic ligaments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Leading the Way to Solutions to the Opioid Epidemic: AOA Critical Issues

BACKGROUND

In the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion.

METHODS

The literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), the impact of strategies on bone and soft-tissue healing, and pain relief are summarized as they relate to the management of orthopaedic injuries and conditions. Additionally, a section on designing solutions to address the current opioid crisis is presented.

RESULTS

The mechanism of action of different classes of analgesic medications is discussed, as well as the basic scientific evidence regarding the impact of narcotic and nonnarcotic analgesic medications on bone-healing and on other organ systems. Differences between pain and nociception, various treatment strategies, and clinical comparisons of the effectiveness of various analgesics compared with opioids are summarized. Finally, options for addressing the opioid crisis, including the description of a large system-wide intervention to impact prescriber behavior at the point of care using health-information solutions, are presented.

CONCLUSIONS

Orthopaedic leaders, armed with information and strategies, can help lead the way to solutions to the opioid epidemic in their respective communities, institutions, and subspecialty societies. Through leadership and education, orthopaedic surgeons can help shape the solution for this critical public health issue.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.

Patterns of Opioid Prescribing for an Orthopaedic Trauma Population

OBJECTIVES

To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center.

DESIGN

A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Adult patients with OT admitted over a 30-day period (n = 110).

INTERVENTION

All discharge and follow-up opioid prescriptions were recorded.

MAIN OUTCOME MEASUREMENTS

Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed.

RESULTS

One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%).

CONCLUSIONS

Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population.

LEVEL OF EVIDENCE

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

Outcomes following non-life-threatening orthopaedic trauma: Why are they considered to be so poor?

The purpose of this review article is to assess the current literature on the outcomes of simple orthopaedic trauma. Simple trauma is defined as the fracture or injury of one limb due to an acute event. Fractures are the most common cause of hospitalized trauma in Australia and associated with multiple social, psychological and physical consequences for patients. The literature to date suggests that there are multiple factors leading to relatively poor outcomes following simple trauma, modifiable and non-modifiable. The most oft cited are older age, lower educational status, being injured at work, injury severity score, pre-existing disease, workers compensation, litigation and pain at initial assessment. Additional psychological risk factors quoted attribute to the injury to an external source and the use of passive coping strategies. This review aims to summarise the relevant literature relating to these risk factors and give direction to improving outcomes and future research into this important area.

Prevalence of Depression and Posttraumatic Stress Disorder After Acute Orthopaedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aims to systematically assess the existing literature and to derive a pooled estimate of the prevalence of depression and posttraumatic stress disorder (PTSD) in adult patients after acute orthopaedic trauma.

DATA SOURCES

A comprehensive search of databases, including MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials databases was conducted through June 2015.

STUDY SELECTION

We included studies that assessed the prevalence of depression or PTSD in patients who experienced acute orthopaedic trauma to the appendicular skeleton or pelvis. Studies with a sample size of ≤10 were excluded.

DATA EXTRACTION

Two authors independently extracted data from the selected studies and the data collected were compared with verify agreement.

DATA SYNTHESIS

Twenty-seven studies and 7109 subjects were included in the analysis. Using a random-effects model, the weighted pooled prevalence of depression was 32.6% (95% CI, 25.0%-41.2%) and the weighted pooled prevalence of PTSD was 26.6% (95% CI, 19.0%-35.9%). Six studies evaluated the prevalence of both depression and PTSD in patients with acute orthopaedic injuries. The weighted pooled prevalence of both depression and PTSD for those patients was 16.8% (95% CI, 9.0%-29.4%).

CONCLUSIONS

Nearly one-third of patients suffer from depression and more than one-quarter of patients suffer from PTSD after an acute orthopaedic injury suggesting that strategies to address both the mental and physical rehabilitation after an orthopaedic injury should be considered to optimize patient recovery.

LEVEL OF EVIDENCE

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

Factors associated with pain intensity and physical limitations after lateral ankle sprains

BACKGROUND

Swelling, tenderness, and ecchymosis don't correlate with time to functional recovery in patients with a lateral ankle sprain. It is established that psychosocial factors such as symptoms of depression and low pain self-efficacy correlate with pain intensity and magnitude of limitations in patients with musculoskeletal disorders.

OBJECTIVE

We studied the correlation between pain self-efficacy or symptoms of depression and (1) ankle specific limitations and (2) pain intensity in patients with a lateral ankle sprain. Further we explored the correlation between estimation of sprain severity (grade) and (3) pain intensity or magnitude of ankle specific limitations.

DESIGN

Eighty-four patients with a lateral ankle sprain prospectively completed the Pain Self Efficacy Questionnaire, the Olerud Molander Ankle Score, Ordinal scale of Pain and the Patient Health Questionnaire-2 at enrollment and the Olerud Molander Ankle Score and the Ordinal scale of Pain three weeks after the injury. Factors associated with higher ankle specific limitations and symptoms were investigated in bivariable and multivariable analysis.

RESULTS

When accounting for confounding factors, greater self-efficacy (p=0.01) and older age (p<0.01) were significantly associated with greater ankle specific symptoms and limitations three weeks after the injury and explained 22% of the variability in ankle specific limitations and symptoms. There was no correlation between the grade of the sprain and pain intensity or ankle specific limitations or symptoms.

CONCLUSIONS

Psychosocial factors (adaptiveness in response to pain in particular) explain more of the variation in symptoms and limitations after ankle sprain than the degree of pathophysiology. The influence of adaptive illness descriptions and recovery strategies based on methods for improving self-efficacy (i.e. cognitive behavioral therapy) might enhance and speed recovery from ankle injuries and merit additional investigation.

LEVEL OF EVIDENCE

Level 2 prospective cohort study.

Military Chronic Musculoskeletal Pain and Psychiatric Comorbidity: Is Better Pain Management the Answer?

Chronic musculoskeletal pain, such as low back pain, often appears in the presence of psychiatric comorbidities (e.g., depression, posttraumatic stress disorder (PTSD)), especially among U.S. military service members serving in the post-9/11 combat era. Although there has been much speculation about how to best address pain/trauma psychiatric symptom comorbidities, there are little available data to guide practice. The present study sought to examine how pre-treatment depression and PTSD influence outcomes in a functional restoration pain management program using secondary analysis of data from the Department of Defense-funded Functional and Orthopedic Rehabilitation Treatment (FORT) trial. Twenty-eight FORT completers were analyzed using a general linear model exploring how well depression and PTSD symptoms predict post-treatment pain (Visual Analog Scale (VAS) pain rating), disability (Oswestry Disability Index; Million Visual Analog Scale), and functional capacity (Floor-to-Waist and Waist-to-Eye Level progressive isoinertial lifting evaluation scores) in a sample of active duty military members with chronic musculoskeletal pain and comorbid depression or PTSD symptoms. Analysis revealed that pre-treatment depression and PTSD symptoms did not significantly predict rehabilitation outcomes from program completers. Implications of these findings for future research on trauma-related pain comorbidities are discussed.

Role of Depression in Outcomes of Low-Energy Distal Radius Fractures in Patients Older Than 55 Years

OBJECTIVES

This study examines depression and outcomes in patients older than 55 years with distal radius fracture.

DESIGN

Prospective data collection included patient characteristics, treatment, general and limb symptoms and disability, and complications at baseline, 3 months, and 1 year. Bivariate analysis and multivariable linear regression were used to assess relationships between depression and outcome measures, specifically the Short Form-36 (SF-36), Disability of the Arm, Shoulder, and Hand (DASH) scores, and the Centre of Epidemiologic Studies Depression (CES-D) scale.

SETTING

The study was conducted in a level-1 trauma center.

PARTICIPANTS

All patients older than 55 years with isolated distal radius fracture were recruited (2007-2011).

INTERVENTION

Patients were treated operatively or nonoperatively.

MAIN OUTCOME MEASURES

The SF-36 and DASH scores measured general and upper extremity status. Depression was measured using CES-D scale. All complications were recorded.

RESULTS

Of 228 patients, 25% were depressed at baseline, 32% at 3 months, and 26% after 1 year. Thirty-two patients (14%) had complications. There was no relationship between depression at baseline and complications; however, there was a statistically significant relationship at 3 months (P = 0.021). There was a statistically significant association between baseline depression and the worse 1-year SF-36. Patients with baseline depression had poorer 1-year DASH scores (20 ± 2.3) than nondepressed patients (11 ± 1.3) (P = 0.0031), and less improvement in DASH scores over the first year (P = 0.023). Multivariable linear regression demonstrated that baseline depression is the strongest predictor of poorer 1-year DASH scores (3.7, P = 0.0078) and change in DASH scores over the first year (2.9, P = 0.026).

CONCLUSIONS

Baseline depression predicts worse function and disability outcomes 1 year from injury. Depression (CES-D ≥16) is the strongest predictor of worse 1-year DASH scores and SF-36 outcome measures, after controlling for other potential predictors.

LEVEL OF EVIDENCE

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

Psychosocial Factors Predict Pain and Physical Health After Lower Extremity Trauma

BACKGROUND

There has been increasing evidence to support the importance of psychosocial factors to poor outcomes after trauma. However, little is known about the contribution of pain catastrophizing and fear of movement to persistent pain and disability.

QUESTIONS/PURPOSES

Therefore, we aimed to determine whether (1) high pain catastrophizing scores are independently associated with pain intensity or pain interference; (2) high fear of movement scores are independently associated with decreased physical health; and (3) depressive symptoms are independently associated with pain intensity, pain interference, or physical health at 1 year after accounting for patient characteristics of age and education.

METHODS

Of 207 eligible patients, we prospectively enrolled 134 patients admitted to a Level I trauma center for surgical treatment of a fracture to the lower extremity. Sixty percent of patients (80 of 134) had an isolated lower extremity injury and the remainder sustained additional minor injury to the head/spine, abdomen/thorax, or upper extremity. Pain catastrophizing was measured with the Pain Catastrophizing Scale, fear of movement with the Tampa Scale for Kinesiophobia, and depressive symptoms with the Patient Health Questionnaire. Pain and physical health outcomes were assessed with the Brief Pain Inventory and the SF-12, respectively. Assessments were completed at 4 weeks and 1 year after hospitalization. Multiple variable hierarchical linear regression analyses were used to address study hypotheses. One hundred ten patients (82%) completed the 1-year followup.

RESULTS

Pain catastrophizing at 4 weeks was associated with pain intensity (β = 0.67; p < 0.001) and pain interference (β = 0.38; p = 0.03) at 1 year. No association was found between fear of movement and physical health (β = 0.15; p = 0.34). Depressive symptoms at 4 weeks were associated with pain intensity (β = 0.49; p < 0.001), pain interference (β = 0.51; p < 0.001), and physical health (β = -0.32; p = 0.01) at 1 year.

CONCLUSIONS

Catastrophizing behavior patterns and depressive symptoms are associated with more severe pain and worse function after traumatic lower extremity injury. Cognitive and behavioral strategies that have proven effective for chronic pain populations may be beneficial for trauma patients. Future research is needed to determine whether the early identification and treatment of subgroups of at-risk patients based on catastrophizing behavior or depressive symptoms can improve long-term outcomes.

LEVEL OF EVIDENCE

Level I, prognostic study.

To What Degree Do Pain-coping Strategies Affect Joint Stiffness and Functional Outcomes in Patients with Hand Fractures?

BACKGROUND

Patients with hand fractures often have pain, swelling, and stiffness in the joints of the hand, which may lead them to protect their hands, resulting in more stiffness and in delayed recovery. However, the effects of pain-coping strategies and catastrophization (the tendency to expect the worst to occur when pain is present, an approach that can be thought of as the opposite of "coping") on functional recovery after hand fractures have not been investigated in depth.

QUESTIONS/PURPOSES

Are preoperative catastrophization and anxiety in patients with hand fractures associated with (1) decreased grip strength; (2) decreased range of motion; and (3) increased disability at 3 and 6 months after surgical treatment for a hand fracture? Secondarily, we asked if there are other patient and injury factors that are associated with these outcomes at 3 and 6 months.

METHODS

A total of 93 patients with surgically treated hand fractures were enrolled in this prospective study. Preoperative assessments measured coping strategies evaluated by measuring catastrophic thinking with the Pain Catastrophizing Scale and pain anxiety with the Pain Anxiety Symptom Scale. At 3 and 6 months postoperatively, grip strength, total active range of motion, and disability (Quick Disabilities of the Arm, Shoulder, and Hand score) were assessed. Bivariate and multivariate analyses were performed to identify patient demographic, injury, and coping skills factors that accounted for outcomes of strength, motion, and disability.

RESULTS

Decreased grip strength was associated with catastrophic thinking (beta = -1.29 [95% confidence interval, -1.67 to -0.89], partial R(2) = 11%, p < 0.001) and anxiety (beta = -0.83 [-1.16 to -0.50], partial R(2) = 7%, p = 0.007) at 3 months, but by 6 months, only anxiety (beta = -0.74 [-1.04 to -0.44], partial R(2) = 7%, p = 0.010) remained an important factor. Decreased total active range of motion was associated with pain catastrophizing (beta = -0.63 [-0.90 to -0.36], partial R(2) = 6 %, p = 0.024) and anxiety (beta = -0.28 [-0.42 to -0.14], partial R(2) = 3%, p = 0.035) at 3 months but not at 6 months. Similarly, increased disability was associated with pain catastrophizing (beta = 1.09 [1.39-0.79], partial R(2) = 12%, p < 0.001) and anxiety (beta = 0.93 [1.21-0.65], partial R(2) = 11%, p = 0.001) at 3 months; these factors failed to be associated for 6-month outcomes.

CONCLUSIONS

Preoperative poor coping skills as measured by high catastrophization and anxiety were associated with a weaker grip strength, decreased range of motion, and increased disability after surgical treatment for a hand fracture at 3 months. However, poor coping skills did not show persistent effects beyond 6 months. More research may be needed to show interventions to improve coping skills will enhance treatment outcome in patients after acute hand fractures.

LEVEL OF EVIDENCE

Level III, prognostic study.