Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury

Is Pain in the Uninjured Leg Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Lower Extremity Injury?

BACKGROUND

Patients recovering from lower extremity injuries often interpret discomfort associated with increased use of the uninjured leg as a potential indication of harm. If expressed concerns regarding contralateral leg pain are associated with unhelpful thinking regarding symptoms, they can signal orthopaedic surgeons to gently reorient these thoughts to help improve comfort and capability during recovery.

QUESTIONS/PURPOSES

We asked: (1) Among people recovering from isolated traumatic lower extremity injury, is pain intensity in the uninjured leg associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Are pain intensity in the injured leg, magnitude of capability, and accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms?

METHODS

Between February 2020 and February 2022, we enrolled 139 patients presenting for an initial evaluation or return visit for any traumatic lower extremity injury at the offices of one of three musculoskeletal specialists. Patients had the option to decline filling out our surveys, but because of the cross-sectional design, required fields on the electronic survey tools, and monitored completion, there were few declines and few incomplete surveys. The median age of participants was 41 years (IQR 32 to 58), and 48% (67 of 139) were women. Fifty percent (70 of 139) injured their right leg. Sixty-five percent (91 of 139) had operative treatment of their fracture. Patients completed measures of pain intensity in the uninjured leg, pain intensity in the injured leg, lower extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis sought factors independently associated with pain intensity in the uninjured leg, pain intensity in the injured leg, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors.

RESULTS

Greater pain intensity in the uninjured leg (regression coefficient [RC] 0.09 [95% CI 0.02 to 0.16]; p < 0.01) was moderately associated with more unhelpful thinking regarding symptoms. This indicates that for every one-unit increase in unhelpful thinking regarding symptoms on the 17-point scale we used to measure pain catastrophizing, pain intensity in the uninjured leg increases by 0.94 points on the 11-point scale that we used to measure pain intensity, holding all other independent variables constant. Greater pain intensity in the injured leg (RC 0.18 [95% CI 0.08 to 0.27]; p < 0.01) was modestly associated with more unhelpful thinking regarding symptoms. Greater pain accommodation (RC -0.25 [95% CI -0.38 to -0.12]; p < 0.01) was modestly associated with less unhelpful thinking regarding symptoms. Greater magnitude of capability was not independently associated with less unhelpful thinking regarding symptoms.

CONCLUSION

A patient's report of concerns regarding pain in the uninjured limb (such as, "I'm overcompensating for the pain in my other leg") can be considered an indicator of unhelpful thinking regarding symptoms. Orthopaedic surgeons can use such reports to recognize unhelpful thinking and begin guiding patients toward healthier thoughts and behaviors.

LEVEL OF EVIDENCE

Level II, prognostic study.

Do Items Addressing Thoughts and Emotions Regarding Symptoms Measure Distinct Aspects of Musculoskeletal Health?

A prior experiment identified separate thought and feeling item groupings among items in measures of unhelpful thinking (ie, catastrophic thinking, kinesiophobia). This study sought to confirm the utility of separating these factors using a subset of selected items. One hundred and thirty-six adult patients visiting a musculoskeletal specialist completed the surveys. Confirmatory factor analysis measured the association between variation in scores on a specific item with variation in scores in separate groupings for thoughts and feelings, and a combined item grouping. Cronbach alpha (internal consistency) and Spearman correlation with magnitude of capability were also measured for the three separate item groupings. The association of variation in specific items with variation in a group of items addressing thoughts, a group of items addressing feelings, and the combination of all items was comparable. The internal consistency and strength of association with magnitude of capability were also comparable. The finding of no advantage to separation of items addressing thoughts and feelings regarding symptoms suggests that just a few items may be able to represent unhealthy mindsets regarding musculoskeletal symptoms.

Is there an association between sleep quality and magnitude of capability?

PURPOSE

Given the stigma surrounding mental health, a discussion of how symptoms interfere with sleep might be a useful first step to identify unhelpful thoughts or feelings of distress. We asked: 1) Does sleep quality have an association with magnitude of incapability and pain intensity independent of mental health? and 2) Are mental health factors associated with sleep quality?

METHODS

We performed a cross-sectional study of one hundred and fifty-four patients seeking musculoskeletal care who completed measures of magnitude of capability, pain intensity, unhelpful thoughts regarding symptoms (catastrophic thinking, negative pain thoughts), distress (symptoms of anxiety and depression), and sleep disturbance. We tested factors associated with the magnitude of capability and pain intensity, accounting for sleep quality and mental health in multivariable models.

RESULTS

Accounting for potential confounding in multivariable analysis, lower magnitude of capability was independently associated with greater sleep disturbance, more unhelpful thoughts about symptoms (negative pain thoughts), and older age. Greater pain intensity was independently associated with greater unhelpful thoughts about symptoms (catastrophic thinking) and not using of an electronic device before bed. Greater sleep disturbance was independently associated with use of sleep medication, greater symptoms of anxiety, and greater unhelpful thoughts regarding symptoms (PCS).

CONCLUSION

Given the observation that sleep disturbance is associated with feelings of anxiety, clinicians can consider starting mental health discussions by focusing on sleep quality. App and web-based cognitive behavioral therapy-based treatments for sleep are readily available and have the potential to improve mental health.

Factors associated with surgeon recognition of mental health care opportunities and inclination to attend to mental health

PURPOSE

A notable percentage of people that die by suicide have had a medical visit within a few months of their death. In a survey-based experiment, we evaluated: 1) whether there are any surgeon, setting, or patient factors associated with surgeon rating of mental health care opportunities, and 2) if there are any surgeon, setting, or patient factors associated with likelihood of mental health referrals.

METHODS

One hundred and twenty-four upper extremity surgeons of the Science of Variation Group viewed five scenarios of a person with one orthopedic condition. The following aspects of the scenarios were independently randomized: Social worker or psychologist available, office workload, socioeconomic status, gender, age, mental health factors, mental health clues, and diagnosis.

RESULTS

Accounting for potential confounders, surgeon likelihood of discussing mental health was associated with cancer, disadvantaged socioeconomic status, mental health factors other than being shy, prior suicide attempt, history of physical or emotional abuse, isolation, and when the office is not busy. Factors independently associated with higher likelihood of referring a patient for mental health care included cancer, disadvantaged socioeconomic status, mental health cues, mental health risk factors, and a social worker or psychologist available in the office.

CONCLUSION

Using random elements in fictitious scenarios we documented that specialist surgeons are aware of and attuned to mental health care opportunities, are motivated to discuss notable cues, and will make mental health referrals, in part influenced by convenience.

Is Pain in the Uninjured Arm Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Upper-Extremity Injury?

PURPOSE

During recovery from upper-extremity injury, patients sometimes express concerns regarding pain associated with increased use of the uninjured limb. Concerns about discomfort associated with increased use may represent a manifestation of unhelpful thoughts such as catastrophic thinking or kinesiophobia. We asked the following questions: (1) Among people recovering from an isolated unilateral upper-extremity injury, is pain intensity in the uninjured arm associated with unhelpful thoughts and feelings of distress regarding symptoms, accounting for other factors? (2) Is pain intensity in the injured extremity, magnitude of capability, or accommodation of pain associated with unhelpful thoughts and feelings of distress regarding symptoms?

METHODS

In this cross-sectional study of new or returning patients presenting to a musculoskeletal specialist for care for an upper-extremity injury, the patients completed scales that were used to measure the following: pain intensity in the uninjured arm, pain intensity in the injured arm, upper-extremity-specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. Multivariable analysis was used to evaluate factors associated with pain intensity in the uninjured arm, pain intensity in the injured arm, magnitude of capability, and pain accommodation, controlling for other demographic and injury-related factors.

RESULTS

Greater pain intensity in both uninjured and injured arms was independently associated with greater unhelpful thinking regarding symptoms. A greater magnitude of capability and pain accommodation were independently associated with less unhelpful thinking regarding symptoms.

CONCLUSIONS

Given that greater pain intensity in the uninjured upper extremity is associated with greater unhelpful thinking, clinicians can be attuned to patient concerns about contralateral pain. Clinicians can facilitate recovery from upper-extremity injury by evaluating the uninjured limb as well as identifying and ameliorating unhelpful thinking regarding symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Does Addressing Mental Health During a Musculoskeletal Specialty Care Visit Affect Patient-rated Clinician Empathy?

BACKGROUND

Unhelpful thoughts and feelings of worry or despair about symptoms account for a notable amount of the variation in musculoskeletal symptom intensity. Specialists may be best positioned to diagnose these treatable aspects of musculoskeletal illness. Musculoskeletal specialists might be concerned that addressing mental health could offend the patient, and avoidance might delay mental health diagnosis and treatment. Evidence that conversations about mental health are not associated with diminished patient experience might increase specialist confidence in the timely diagnosis and initial motivation to treat unhelpful thoughts and feelings of worry or despair.

QUESTIONS/PURPOSES

Using transcripts of videotaped and audiotaped specialty care visits in which at least one instance of patient language indicating an unhelpful thought about symptoms or feelings of worry or despair surfaced, we asked: (1) Is clinician discussion of mental health associated with lower patient-rated clinician empathy, accounting for other factors? (2) Are clinician discussions of mental health associated with patient demographics, patient mental health measures, or specific clinicians?

METHODS

Using a database of transcripts of 212 patients that were audio or video recorded for prior studies, we identified 144 transcripts in which language reflecting either an unhelpful thought or feelings of distress (worry or despair) about symptoms was detected. These were labeled mental health opportunities. Patients were invited on days when the researcher making video or audio records was available, and people were invited based on the researcher's availability, the patient's cognitive ability, and whether the patient spoke English. Exclusions were not tracked in those original studies, but few patients declined. There were 80 women and 64 men, with a mean age of 45 ± 15 years. Participants completed measures of health anxiety, catastrophic thinking, symptoms of depression, and perceived clinician empathy. Factors associated with perceived clinician empathy and clinician discussion of mental health were sought in bivariate and multivariable analyses.

RESULTS

Greater patient-rated clinician empathy was not associated with clinician initiation of a mental health discussion (regression coefficient 0.98 [95% confidence interval 0.89 to 1.1]; p = 0.65). A clinician-initiated mental health discussion was not associated with any factors.

CONCLUSION

The observation that a clinician-initiated mental health discussion was not associated with diminished patient ratings of clinician empathy and was independent from other factors indicates that generally, discussion of mental health does not harm patient-clinician relationship. Musculoskeletal clinicians could be the first to notice disproportionate symptoms or misconceptions and distress about symptoms, and based on the evidence from this study, they can be confident about initiating a discussion about these mental health priorities to avoid delays in diagnosis and treatment. Future studies can address the impact of training clinicians to notice unhelpful thoughts and signs of distress and discuss them with compassion in a specialty care visit; other studies might evaluate the impact of timely diagnosis of opportunities for improvement in mental health on comfort, capability, and optimal stewardship of resources.

There is Little or No Association Between Independently Assessed Communication Strategies and Patient Ratings of Clinician Empathy

BACKGROUND

Quality of care is increasingly assessed and incentivized using measures of patient-reported outcomes and experience. Little is known about the association between measurement of clinician communication strategies by trained observers and patient-rated clinician empathy (a patient-reported experience measure). An effective independent measure could help identify and promote clinician behaviors associated with good patient experience of care.

QUESTIONS/PURPOSES

(1) What is the association between independently assessed clinician communication effectiveness and patient-rated clinician empathy? (2) Which factors are associated with independently assessed communication effectiveness?

METHODS

One hundred twenty adult (age > 17 years) new or returning patients seeking musculoskeletal specialty care between September 2019 and January 2020 consented to video recording of their visit followed by completion of questionnaires rating their perceptions of providers' empathy levels in this prospective study. Patients who had operative treatment and those who had nonoperative treatment were included in our sample. We pooled new and returning patients because our prior studies of patient experience found no influence of visit type and because we were interested in the potential influences of familiarity with the clinician on empathy ratings. We did not record the number of patients or baseline data of patients who were approached, but most patients (> 80%) were willing to participate. For 7% (eight of 120 patients), there was a malfunction with the video equipment or files were misplaced, leaving 112 records available for analysis. Patients were seen by one provider among four attending physicians, four residents, or four physician assistants or nurse practitioners. The primary study question addressed the correlation between patient-rated clinician empathy using the Jefferson Scale of Patient Perceptions of Physician Empathy and clinician communication effectiveness, independently rated by two communication scholars using the Liverpool Communication Skills Assessment Scale. Based on a subset of 68 videos (61%), the interrater reliability was considered good for individual items on the Liverpool Communication Skills Assessment Scale (intraclass correlation coefficient [ICC] 0.78 [95% confidence interval (CI) 0.75 to 0.81]) and excellent for the sum of the items (that is, the total score) (ICC = 0.92 [95% CI 0.87 to 0.95]). To account for the potential association of personal factors with empathy ratings, patients completed measures of symptoms of depression (the Patient-Reported Outcome Measurement Information System depression computerized adaptive test), self-efficacy in response to pain (the two-item Pain Self-Efficacy Questionnaire), health anxiety (the five-item Short Health Anxiety Inventory), and basic demographics.

RESULTS

Accounting for potentially confounding variables, including specific clinicians, marital status, and work status in the multivariable analysis, we found higher independent ratings of communication effectiveness had a slight association (odds ratio [OR] 1.1 [95% CI 1.0 to 1.3]; p = 0.02) with higher (dichotomized) ratings of patient-rated clinician empathy, while being single was associated with lower ratings (OR 0.40 [95% CI 0.16 to 0.99]; p = 0.05). Independent ratings of communication effectiveness were slightly higher for women (regression coefficient 1.1 [95% CI 0.05 to 2.2]); in addition, two of the four attending physicians were rated notably higher than the other 10 participants after controlling for confounding variables (differences up to 5.8 points on average [95% CI 2.6 to 8.9] on a 36-point scale).

CONCLUSION

The observation that ratings of communication effectiveness by trained communication scholars have little or no association with patient-rated clinician empathy suggests that either effective communication is insufficient for good patient experience or that the existing measures are inadequate or inappropriate. This line of investigation might be enhanced by efforts to identify clinician behaviors associated with better patient experience, develop reliable and effective measures of clinician behaviors and patient experience, and use those measures to develop training approaches that improve patient experience.

LEVEL OF EVIDENCE

Level I, prognostic study .

The mind and the hand

Symptoms are determined in large part by mindsets. Feelings of distress and unhelpful thoughts (misinterpretations) of symptoms account for much of the variability in comfort and capability with the severity of the underlying pathophysiology making a more limited contribution. Incorporating this experimental evidence into the daily practice of hand surgery will help us find ways to develop healthy mindsets, to prioritize the alleviation of distress and the gentle redirection of unhelpful thoughts, to avoid unnecessary surgery, and to provide better psychological and social support for people recovering from injury and surgery.

Preliminary study of elastic-tension digital neoprene orthoses for proximal interphalangeal joint flexion contracture

Flexion contracture of the proximal interphalangeal joint (PIPJ) is one of the most frequent complications in finger trauma. Orthoses are the most widely used method to optimize total end-range time (TERT). No previous studies showed that an elastic tension orthosis could be applied for longer than 12 h. We aimed to demonstrate that the elastic-tension digital neoprene orthosis (ETDNO) can achieve higher TERT and therefore better range of motion than other elastic-tension orthoses (ETO) described in the literature. A prospective study of treatment of PIPJ flexion contracture included 10 PIP joints in 8 patients who met the selection criteria. They were instructed to use the ETDNO for around 23 h per day as far as possible, during a period of 3 weeks. Patients reported a mean TERT of 20.6 h a day. PIPJ contracture improved by a mean Torque Range of Motion (TROM) of 23.5° at 500 g and 22.9° at 800 g of passive extension force during the 3-week treatment. Based on the results of this study, the ETDNO appears to offer a highly effective approach for improving PIPJ flexion contracture, increasing range of motion in extension. ETDNO's efficacy probably lies in the significantly improved comfort and low-profile design, enabling excellent compliance and thus optimizing TERT. LEVEL OF EVIDENCE: Level III.

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit?

Objective

To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit.

Methods

A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales.

Results

Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration.

Conclusion

Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration.

Innovation

Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness.

Level of evidence

N/a.

Patient symptom exaggeration is associated with communication effectiveness and trust

Objective

Patients might exaggerate their symptoms in an attempt to align the clinician's views with their own. A person who sees potential benefit in symptom exaggeration might also experience less trust, more difficulty communicating, and lower satisfaction with their clinician. We asked if there was an association between patient rating of communication effectiveness, patient satisfaction, and patient trust with symptom exaggeration?

Methods

One hundred and thirty-two patients in four orthopaedic offices completed surveys including demographics, Communication-Effectiveness-Questionnaire (CEQ-6), Negative-Pain-Thoughts-Questionnaire (NPTQ-4), a Guttman-style satisfaction question, PROMIS Depression, and Stanford Trust in Physician. Patients were randomly assigned to answer three questions about symptom exaggeration for two scenarios: 1) their own exaggeration during the just-completed visit or 2) the average person's tendency to exaggerate.

Results

In multivariable analysis, lower ratings of communication effectiveness were associated with greater symptom exaggeration (p=0.002), while an annual household income>$100,000 (p=0.033) was associated with higher ratings. Higher rating of satisfaction was associated with lower education attained (p=0.004). Greater trust was associated with lower personal exaggeration (p=0.002).

Conclusion

The relationship between greater exaggeration and lower ratings of communication effectiveness and trust suggests that symptom descriptions that seem more intense or diffuse than expected may indicate opportunities for more effective communication and trust.

Innovation

Patient experience can be improved by training clinicians to identify symptom exaggeration as a signal that the patient does not feel heard and understood and a cue to return to communication strategies that build trust.

Recovery After Musculoskeletal Injury: Mental and Social Health

Recovery from injury involves painful movement and activity, painful stretches and muscle strengthening, and adjustment to permanent impairment. Recovery is facilitated by embracing the concept that painful movement can be healthy, which is easier when one has more hope, less worry, and greater social supports and security. Evolution of one's identity to match the new physical status is a hallmark of a healthy outcome and is largely determined by mental and social health factors. When infection, loss of alignment or fixation, and nerve issues or compartment syndrome are unlikely, greater discomfort and incapability that usual for a given pathology or stage of recovery signal opportunities for improved mental and social health. Surgeons may be the clinicians most qualified to make this discernment. A surgeon who has gained a patient's trust can start to noticed despair, worry, and unhelpful thinking such as fear of painful movement. Reorienting people to greater hope and security and a healthier interpretation of the pains associated with the body's recovery can be initiated by the surgeon and facilitated by social workers, psychologist, and physical, occupational and hand therapists trained in treatments that combine mental and physical therapies.

There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS

Background

The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.

Methods

This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population.

Results

We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017.

Conclusion

Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00440-3.

The impact of self-efficacy on nonoperative treatment of atraumatic shoulder pain

CONTEXT

Atraumatic shoulder pain is frequently encountered in primary care and surgical clinics. With increased recognition of the biopsychosocial model, there has been an increased emphasis on identifying patient factors associated with less effective coping strategies such as pain catastrophizing. It remains uncertain what impact self-efficacy has on the response to nonoperative treatment of shoulder pain.

OBJECTIVES

Our purpose is to determine the influence of patient coping strategies (self-efficacy) on the outcome of nonoperative treatment of atraumatic shoulder pain. We hypothesize that higher levels of self-efficacy are associated with increased self-reported function after nonoperative treatment.

METHODS

We conducted a retrospective case-control study for a consecutive series of patients seen in our clinic with nonoperatively managed atraumatic shoulder pain. Baseline demographics and range of motion were recorded. Patients completed the Simple Shoulder Test (SST), PROMIS Pain Interference (PI), and PROMIS Self-Efficacy for Managing Symptoms (SE). After 3 months of nonoperative treatment, patients were placed into two groups: patients who clinically improved (Group 1) and those that did not (Group 2), with clinical improvement defined as an increase of 2 or greater on the SST.

RESULTS

Seventy-eight patients returned for follow-up and completed all questionnaires. There were no statistically significant differences for age, sex, or tobacco use between the two groups. Half of the patients in our series had symptoms for >12 months, with rotator cuff syndrome being the most frequent diagnosis (40.0%). Patients in Group 1 had significantly higher PROMIS SE scores (42 vs. 39, p=0.0094) at initial evaluation. At 3-month follow-up, patients in Group 1 also had significantly lower Numeric Pain Rating Scale (NPRS) scores (4.5 vs. 6.5, p=0.0067), compared to Group 2.

CONCLUSIONS

Patients who experience clinical improvement with nonoperative treatment of atraumatic shoulder conditions demonstrate higher self-efficacy than patients who fail to improve. Guiding patients with atraumatic shoulder pain and low self-efficacy toward interventions aimed at improving coping strategies, rather than addressing musculoskeletal factors alone, may contribute to the goal of improving outcomes.

Unhelpful Thoughts and Distress Regarding Symptoms Limit Accommodation of Musculoskeletal Pain

BACKGROUND

Among people with musculoskeletal disorders, much of the variation in magnitude of incapability and pain intensity is accounted for by mental and social health opportunities rather than severity of pathology. Current questionnaires seem to combine distinct aspects of mental health such as unhelpful thoughts and distress regarding symptoms, and they can be long and burdensome. To identify personalized health strategies, it would be helpful to measure unhelpful thoughts and distress regarding symptoms at the point of care with just a few questions in a way that feels relevant to a person's health.

QUESTIONS/PURPOSES

(1) Do questions that address unhelpful thoughts and distress regarding symptoms independently account for variation in accommodation of pain? (2) Which questions best measure unhelpful thoughts and distress regarding symptoms?

METHODS

This is a cross-sectional questionnaire study of people seeking care regarding upper and lower extremity conditions from one of eight specialist clinicians (one upper extremity, one arthroplasty, and one sports surgeon and their three nurse practitioners and two physician assistants) in one urban office. Between June 2020 and September 2020, 171 new and returning patients were approached and agreed to participate, and 89% (153) of patients completed all questionnaires. The most common reason for noncompletion was the use of a pandemic strategy allowing people to use their phone to finish the questionnaire, with more people leaving before completion. Women and divorced, separated, or widowed people were more likely to not complete the survey, and we specifically account for sex and marital status as potential confounders in our multivariable analysis. Forty-eight percent (73 of 153) of participants were women, with a mean age 48 ± 16 years. Participants completed demographics and the validated questionnaires: Pain Catastrophizing Scale, Negative Pain Thoughts Questionnaire, Tampa Scale of Kinesiophobia, Intolerance of Uncertainty Scale, and Pain Self-Efficacy Questionnaire (a measure of accommodation to pain). In an exploratory factor analysis, we found that questions group together on four topics: (1) distress about symptoms (unhelpful feelings of worry and despair), (2) unhelpful thoughts about symptoms (such as worst-case thinking and pain indicating harm), (3) being able to plan, and (4) discomfort with uncertainty. We used a multivariable analysis, accounting for potential confounding demographics, to determine whether the identified question groupings account for variation in accommodation of pain-and thus are clinically relevant. Then, we used a confirmatory factor analysis to determine which questions best represent clinically relevant groupings of questions.

RESULTS

After accounting for sex, marital status, work, and income, we found that distress and unhelpful thoughts about symptoms were independently associated with accommodation of pain, and together, they explained 60% of its variation (compared with 52% for distress alone and 40% for unhelpful thoughts alone). Variation in symptoms of distress was best measured by the question "I feel I can't stand it anymore" (76%). Variation in unhelpful thoughts was best addressed by the question "I wouldn't have this much pain if there wasn't something potentially dangerous going on in my body" (64%).

CONCLUSION

We found that distress (unhelpful feelings) and unhelpful thoughts about symptoms are separate factors with important and comparable associations with accommodation to pain. It also appears that these two factors can be measured with just a few questions. Being attentive to the language people use and the language of influential questions might improve clinician identification of mental health opportunities in the form of distress and unhelpful thoughts about symptoms, which in turn might contribute to better accommodation and alleviation of symptoms.

LEVEL OF EVIDENCE

Level II, prognostic study.

American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Early Screening for Psychosocial Risk and Protective Factors

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons (AAOS) have developed Appropriate Use Criteria for the Early Screening for Psychosocial Risk and Protective Factors. Evidence and clinical expertise were used to develop criteria for addressing mental and social health opportunities to help people recover from musculoskeletal injuries to the extremity, spine, and pelvis. The criteria were developed by identifying observable symptoms and results of screening that suggest mental and social health challenges among patients with lower extremity trauma in clinical practice. The 32 patient scenarios and three interventions (evaluate for psychological distress, evaluate for social health opportunities, and evaluate coping and resilience strategies) were developed by the writing panel of clinicians who are specialists in mental and social health in musculoskeletal illness. Next, a separate, multidisciplinary, voting panel made up of specialists and nonspecialists rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3). Notably, with a high level of agreement, the voting panel determined that interventions to address mental and social health were appropriate in all scenarios as follows: 86% were rated appropriate, 14% were rated possibly appropriate, and none were rated rarely appropriate.

Prospective Cohort Study to Investigate Factors Associated With Continued Immobilization of a Nondisplaced Scaphoid Waist Fracture

PURPOSE

The decision to continue immobilization of a nondisplaced scaphoid waist fracture is often based on radiographic appearance (despite evidence that radiographs are unreliable and inaccurate for diagnosing scaphoid union 6-12 weeks after fracture) and fracture tenderness (even though it is influenced by cognitive biases on pain). This may result in unhelpful additional immobilization. We studied nondisplaced scaphoid waist fractures to determine the factors associated with (1) the surgeon's decision to continue cast or splint immobilization at the first visit when cast removal was being considered; (2) greater pain on examination; and (3) the surgeon's concern about radiographic consolidation.

METHODS

We prospectively included 46 patients with a nondisplaced scaphoid waist fracture treated nonoperatively. At the first visit when cast removal was considered - after an average of 6 weeks of immobilization - patients rated pain during 4 examination maneuvers. The treating surgeon assessed union on radiographs and decided whether to continue or discontinue immobilization. Patients completed measures of the following: (1) the degree to which pain limits activities (Patient-Reported Outcome Measure Interactive System [PROMIS] Pain Interference Computer Adaptive Test [CAT], Pain Self-Efficacy Questionnaire-2); (2) symptoms of depression (PROMIS Depression CAT); and (3) upper extremity function (PROMIS Upper Extremity Function CAT). We used multivariable regression analysis to investigate the factors associated with each outcome.

RESULTS

Perceived inadequate radiographic healing and greater symptoms of depression were independently associated with continued immobilization. Pain during the examination was not associated with continued immobilization. Patient age was associated with pain on examination. Shorter immobilization duration was the only factor associated with the surgeon's perception of inadequate radiographic consolidation.

CONCLUSIONS

Inadequate radiographic healing and greater symptoms of depression are associated with a surgeon's decision to continue cast or splint immobilization of a nondisplaced scaphoid waist fracture.

CLINICAL RELEVANCE

Overreliance on radiographs and inadequate accounting for psychological distress may hinder the adoption of shorter immobilization times for nondisplaced waist fractures.

What factors are associated with perceived disease onset in patients with hip and knee osteoarthritis?

Introduction

Newly symptomatic osteoarthritis (OA) is often misinterpreted as new pathology or injury, which is associated with pain intensity and incapability.

Methods

Adult patients with hip and knee OA completed measures of catastrophic thinking, depression, capability, symptom duration, and perceived injury.

Results

Symptom duration was associated with OA grade and symptoms of depression. Perceived injury was common (31%) and associated with men and knee arthritis. Capability was associated with misinterpretation of symptoms and the work status 'other,' but not radiographic severity.

Conclusions

Misinterpretation of OA symptoms is common and has a greater influence on capability than radiographic grade of pathophysiology.

Talking points for the safe and effective alleviation of pain

Evidence suggests that the alleviation of pain is enhancedby a strong patient-clinician relationship and attending to a patient’s social and mental health. There is a limited role for medication, opioids in particular.

Orthopaedic surgeons can use comprehensive biopsychosocial strategies to help people recover and can work with colleagues who have the appropriate expertise in order to maximize pain alleviation with optimal opioid stewardship.

Preparing patients for elective surgery and caring for them after unplanned injury or surgery can benefit from planned and practiced strategies based in communication science.

Cite this article: Bone Joint J 2020;102-B(9):1122–1127.

The Handshake Test: A Nonverbal Assessment of Coping Strategies and Functional Status in Patients with Atraumatic Upper-Extremity Conditions

BACKGROUND

Maladaptive coping strategies can lead to less functional improvement after upper-extremity surgery. It remains uncertain how well surgeons can recognize signs of less effective coping strategies in patients in the absence of formalized questionnaires. Our purpose is to determine if the "Handshake Test" can be used to identify patients with less effective coping strategies. We hypothesize that a simple physical examination finding (a refusal or inability to shake hands) is associated with higher pain level, maladaptive coping strategies and decreased functional status.

METHODS

We prospectively analyzed 246 consecutive new patients presenting to one of three surgeons with atraumatic upper-extremity conditions. Patients completed a pain scale (NPRS) and PROMIS instruments including Self-Efficacy (SE) for Managing Symptoms, Pain Interference (PI) and Upper Extremity (UE). Each surgeon recorded a refusal to shake hands as part of a normal greeting, referred to as a "positive Handshake Test".

RESULTS

200 patients (81%) patients completed all outcome measures and were included in our analysis. 8% demonstrated a positive Handshake Test. Patients with a positive Handshake Test were more likely to use tobacco; otherwise baseline demographics were similar between the two groups. Patients with a positive Handshake Test demonstrated higher pain scores (NPRS and PROMIS PI), lower levels of self-efficacy and worse self-reported functional status on the PROMIS UE.

CONCLUSIONS

For patients with atraumatic upper-extremity conditions, those with a positive Handshake Test report higher pain levels, lower self-efficacy, and decreased self-reported functional status than patients who can perform a handshake. This simple test can aid in identifying patients with less effective coping strategies, allowing surgeons to guide patients towards interventions to improve both illness behavior and functional outcomes.Level of Evidence: II.

Patient Characteristics, Treatment, and Presenting PROMIS Scores Associated with Number of Office Visits for Traumatic Hand and Wrist Conditions

BACKGROUND

Overuse of healthcare resources is burdensome on society. Prior research has demonstrated that many patients with traumatic musculoskeletal injuries continue to seek care long after appropriate healing is well established, suggesting an overuse of services. However, few studies have examined the factors-including patient-reported outcomes-associated with an increased number of clinic visits for traumatic hand and wrist conditions.

QUESTIONS/PURPOSES

(1) After accounting for surgical treatment, surgeon, and demographic factors, is a patient's PROMIS Pain Interference score associated with the total number of office visits? (2) Is PROMIS Depression, combination of PROMIS Depression and Pain Interference, or Physical Function scores associated with the number of office visits?

METHODS

Between June 2015 and May 2018, 1098 patients presenting for a new patient visit at a single, urban academic medical center for distal radius fracture, wrist or hand sprain, tendon rupture, traumatic finger amputation, or scaphoid fracture were identified. Of those, 823 (75%) patients completed all PROMIS domains and presented before the trailing period and thus were included in this retrospective study. We recorded a number of variables including: Total number of office visits, age, sex, race, marital status, diagnosis, provider, and operative or nonoperative treatment. Multivariable Poisson regression analysis was conducted to determine whether Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI), Physical Function (PROMIS PF), and Depression scores measured at the first visit were associated with the total number of office visits, after accounting for the other factors we measured.

RESULTS

Higher PROMIS PI scores were associated with greater number of clinic visits (0.0077; 95% CI, 0.0018-0.014; p = 0.010). Although PROMIS Depression scores were not associated with the number of office visits (0.0042; 95% CI, -0.0099 to 0.0094; p = 0.112), higher PROMIS PF scores were associated with fewer office visits when accounting for confounding variables (-0.0077; 95% CI, -0.0012 to -0.0029; p = 0.001). Additionally, across all individual PROMIS models, there was an association between the variables "operative treatment" (PI: 0.85; 95% CI, 0.72-0.98; p < 0.001; Depression: 0.87; 95% CI, 0.74-1.0; p < 0.001; PF: 0.85; 95% CI, 0.72-0.99; p < 0.001) and "traumatic finger amputation" (PI: 0.22; 95% CI, 0.016-0.42; p = 0.034; Depression: 0.2; 95% CI, 0.086-0.47; p = 0.005; PF: 0.21; 95% CI, 0.014-0.41; p = 0.036) with an increased total number of office visits. Provider team 5 (PI: -0.62; 95% CI, -0.98 to -0.27; p = 0.001; Depression: -0.61; 95% CI, -0.96 to -0.26; p = 0.001; PF: -0.60; 95% CI, -0.96 to -0.25; p = 0.001) was associated with fewer office visits. In both the PROMIS Depression and PROMIS PF regression models, increasing age (Depression: -0.0048; 95% CI, -0.0088 to -0.00081; p = 0.018; PF: -0.0045; 95% CI, -0.0085 to -0.0006; p = 0.024) was also associated with fewer total number of office visits.

CONCLUSIONS

This study helps surgeons understand that patients who present at their initial office visit for traumatic hand and wrist conditions displaying worse pain coping strategies and decreased physical function will have more office visits. We recommend that surgeons engage in a comprehensive care approach that is empathetic, fosters effective pain coping strategies (and so might decrease PROMIS PI scores), and educates patients about expectations by providing educational materials and/or including other health professionals (such as, social work, physical therapy, mental health professional) as needed. This may decrease healthcare use in patients with traumatic hand and wrist conditions.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Cost, Value, and Patient Satisfaction in Carpal Tunnel Surgery

The cost of carpal tunnel release (CTR) surgery can be decreased and patient satisfaction increased by a few relatively simple changes. Although cost estimates vary in the literature, most investigators agree that open CTR costs less than endoscopic CTR, and the clinic procedure room or ambulatory surgery center is cheaper than the ambulatory surgery center, which is less than the hospital. Patient satisfaction can be increased by making office visits more patient-centered and improving the quality of dialogue between the surgeon and patient.

Fear of movement and its effects on hand function after tendon repair

After tendon injuries, it has been observed clinically that patient-reported disability is more severe than the patient's actual performance. This is thought to result from a fear of movement (kinesiophobia) after surgery. The aim of this study was to investigate the presence of kinesiophobia in this patient population and its effects on the clinical outcomes. Patients (n=118) with tendon repairs were included. All the participants received early passive mobilization and were assessed at the end of the 8th week. Grip and pinch strengths were measured and the Nine-Hole Peg Test (9HPT) was conducted. Patients also filled out the Michigan Hand Outcomes Questionnaire (MHOQ) and Tampa Scale for Kinesiophobia (TSK). Patients were divided according to their kinesiophobia: Group 1 with low kinesiophobia (TSK<37) and Group 2 with high kinesiophobia (TSK≥37). The groups were compared on the assessed parameters. Fifty-nine percent of the patients had a high kinesiophobia level. The performance-based test results were similar between the groups (P>0.05). Patient-reported MHOQ and TSK scores were significantly lower in the high kinesiophobic group (P=0.001 and P=0.000, respectively). Patients with tendon repairs often develop kinesiophobia, which may contribute to difficulty when starting to re-use their hand in daily life. None of the objective results were affected by this fear of movement-only patient-reported disability. Clinicians should be aware that clinical outcomes may be affected by the patient's kinesiophobic thinking and must be cautious during treatment.