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OBJECTIVES: To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures. DESIGN: Secondary use of longitudinal data. SETTING: Single Level-1 trauma center in Oxford, United Kingdom. PATIENT SELECTION: English-speaking adults with isolated proximal humerus, elbow, or distal radius fracture managed operatively or nonoperatively were included, and those with multiple fractures or cognitive deficit were excluded. OUTCOME MEASURES AND COMPARISONS: Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2-4 weeks, and 6-9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on OTA/AO classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture-related aspects. RESULTS: Among 703 included patients (age 59 ± 21 years, 66% women, 16% high-energy injury), 4 statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: ß = 4.1, 3: ß = 7.5, and 4: ß = 17) and pain intensity (group 3: ß = 0.70 and 4: ß = 1.4) (P < 0.01). Higher fracture severity (ß = 4.5), high-energy injury (ß = 4.0), and nerve palsy (ß = 8.1) were associated with worse baseline incapability (P < 0.01), and high-energy injury (ß = 0.62) and nerve palsy (ß = 0.76) with worse baseline pain intensity (P < 0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (ß = 1.3, ß = 7.0) and pain intensity (ß = 0.19, ß = 1.1) (P < 0.02). CONCLUSIONS: Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high-energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Recuperación de la Función , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Longitudinales , Reino Unido , Adulto , Anciano , Fracturas Óseas/psicología , Estudios de Cohortes , Dimensión del Dolor , Fracturas del Radio/psicología , Fracturas del Radio/cirugía , Fracturas del Hombro/psicologíaRESUMEN
INTRODUCTION: Distal radius fracture (DRF) is one of the most common upper extremity fractures treated by hand therapists and can lead to chronic physical impairment and reduced occupational performance. This scoping review aimed to reveal what is currently known about occupational performance following DRF and to explore if and how occupational performance is defined and considered in the research. METHODS: This review was guided by the PRISMA-Scoping review and the Joanna Briggs Institute (JBI) guidelines. Relevant databases were searched, and studies that addressed occupation performance in adult participants following DRF were included. The findings were summarised according to the components of occupational performance (person, occupation, and environment), and quality was measured using the Mixed Methods Appraisal Tool. RESULTS: Forty-three articles met the eligibility criteria for inclusion. All of the studies discussed at least two components of occupational performance, while 25 recognised all three. The consideration of occupational performance was dominated by biomechanical issues associated with the person component (i.e. range of motion, strength). There was some acknowledgement of the psychosocial aspects of the person and, to a lesser extent, the environment, as well as the impact of both on return to occupational performance. CONCLUSION: Despite occupational performance being at the core of occupational therapy theory, its consideration within the context of research on DRF appears to be focussed on the person component of occupational performance and on biomechanical issues. Further research is recommended to determine how much this reflects current clinical practice and if a more comprehensive consideration of occupational performance will improve rates of recovery following DRF. CONSUMER AND COMMUNITY INVOLVEMENT: As part of the protocol development for this review, consumers and stakeholders were consulted. They provided feedback on clarity and importance of the research questions. PLAIN LANGUAGE SUMMARY: A distal radius fracture happens when you break the bone on the thumb side of your wrist. This type of injury often occurs when you fall and land on an outstretched hand. It is one of the more common injuries that hand therapists see in their practice. For some people, recovering from this fracture can take a long time and come with a lot of pain, difficulty moving, and emotional stress. These problems can make it hard to do everyday things like driving, cooking, or getting dressed. It can also affect both paid and unpaid work as well as leisure and social activities, making life more difficult for everyone involved. The findings from this review suggest that the current research usually focuses on how the body physically heals from this type of injury, but it does not pay as much attention to the emotional and social impact on healing. Also, it does not always discuss the activities that are important to the person, or the environment where they live, work, and socialise. This may show a gap in the research regarding our full comprehension of recovery from distal radius fractures. Taking a broader view and approach to recovery, considering a person's emotions, social life, environment, and daily activities, could help people recover fully and get back to their previous life routines and roles after this type of injury.
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Terapia Ocupacional , Fracturas del Radio , Humanos , Fracturas del Radio/rehabilitación , Fracturas del Radio/psicología , Terapia Ocupacional/métodos , Recuperación de la Función , Rango del Movimiento Articular , Fenómenos Biomecánicos , Fracturas de la MuñecaRESUMEN
BACKGROUND: Distal radius fractures are a common presentation in emergency departments. Synthesis of qualitative research of treatment, care and rehabilitation this fracture presents from the patient perspective could improve clinical practice and care. The purpose of this systematic review was to synthesize the qualitative literature on patient experiences after sustaining a distal radius fracture. METHODS: We searched Embase, MEDLINE, CINAHL, Psycinfo and CINAHL to identify qualitative studies published from database conception to May 2023. All studies were screened, extracted, analysed and quality assessed by two blinded reviewers. A thematic synthesis approach was used to analyse the findings from included studies. RESULTS: A total of 9 studies interviewing 160 unique patients were included. We identified 3 themes in relation to patient experiences after sustaining a distal radius fracture: 1) Concerns about dependency, 2) Fear and pain and 3) Motivators for recovery. The themes did not exist as sharply demarcated topics but were intertwined with patients reflecting that more information and knowledge could assist in managing expectations and the recovery period. CONCLUSION: Our synthesis highlighted that adult patients with DRF experience a lack of information about the care and treatment inhibiting independence and successful management of expectations due to pain, fear and lack of motivation. Our findings can inform orthopaedic units and assist in tailoring information to patient needs.
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Investigación Cualitativa , Fracturas del Radio , Humanos , Fracturas del Radio/psicología , Adulto , Fracturas de la MuñecaRESUMEN
BACKGROUND: Sensorimotor impairment following distal radius fracture (DRF) has been associated with a significant decline in function. Joint position sense (JPS) testing is a meaningful and responsive way to assess sensorimotor impairment for individuals who have sustained a DRF; however, there are factors that may influence the results of JPS testing, including kinesiophobia and pain intensity. PURPOSE: This study aimed to evaluate the influence kinesiophobia may have on wrist JPS testing and if pain intensity impacts kinesiophobia and JPS in individuals with a DRF. STUDY DESIGN: This was a cross-sectional study. METHODS: Participants referred from two medical centers with a diagnosis of DRF treated with at least 3 weeks of immobilization were enrolled in the study. Data were collected at 1 week and 6 weeks postimmobilization period. Demographics were summarized with descriptive statistics, and linear relationships between kinesiophobia, pain intensity, and wrist JPS were examined using Pearson correlation coefficient. RESULTS: Forty-eight participants were included in this study (mean age 42.9 years). Significant positive correlations were found between the Tampa Scale for Kinesiophobia (TSK) and Numeric Rating Scale (NRS; r = 0.951, p < 0.001), TSK and JPS error (r = 0.942, p < 0.001), as well as NRS and JPS error (r = 0.898, p < 0.001). These correlations indicate that higher levels of kinesiophobia are associated with increased pain intensity and greater JPS error. T-tests reveal no significant difference between male and female for the TSK, NRS, or JPS scores. CONCLUSIONS: There is an association for individuals with high levels of kinesiophobia and both greater pain and errors with JPS testing.
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Dimensión del Dolor , Trastornos Fóbicos , Fracturas del Radio , Humanos , Estudios Transversales , Femenino , Masculino , Fracturas del Radio/psicología , Adulto , Persona de Mediana Edad , Trastornos Fóbicos/diagnóstico , Trastornos Fóbicos/psicología , Propiocepción/fisiología , Articulación de la Muñeca/fisiopatología , Anciano , Fracturas de la Muñeca , KinesiofobiaRESUMEN
PURPOSE: This systematic review aimed to understand older people's perspectives of associated fear-avoidant beliefs following upper limb fracture. METHODS: Published and unpublished literature databases were systematically searched from inception to 1st April 2023. Qualitative studies reporting the perspectives of fear-avoidant beliefs or behaviours in people who had sustained an upper limb fracture were eligible. Data extracted included characteristics of people interviewed, experiences and perceptions of fear, fear of falling, and fear-avoidant beliefs and behaviours. Data were synthesised using a meta-ethnography approach and the GRADE-CERQUAL tool. RESULTS: Eight studies were eligible (n = 150 participants; 109 distal radial/41 humeral fracture). Three overarching themes were identified: (1) type of fear-avoidant experiences, (2) drivers of fear-avoidant beliefs and behaviours, and (3) consequences of fear-avoidant beliefs and behaviours. The themes generated were based on moderate confidence evidence. In summary, whilst some patients initially consider upper limb fractures to be relatively minor injuries, over time, the realisation occurs that they have wide-ranging consequences with longer-term perspectives on recovery. This often occurs following an initial period of reduced fear. Providing education and support immediately post-fracture to prevent or challenge initial health beliefs around fear of falls and fear of movement is imperative to recovery. CONCLUSIONS: Fear-avoidant beliefs can impact heavily on certain older people's recovery, as well as their longer-term health and wellbeing. Consideration of fear avoidance and taking steps to mitigate against this in the acute upper limb trauma setting will better serve these patients in their ongoing recovery from injury.
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Accidentes por Caídas , Miedo , Humanos , Miedo/psicología , Anciano , Antropología Cultural , Fracturas del Húmero/psicología , Fracturas del Radio/psicología , Conocimientos, Actitudes y Práctica en SaludRESUMEN
Self-efficacy for managing injury may contribute to variation in clients' support needs after distal radius fracture (DRF). This study aimed to (a) explore associations between self-efficacy for managing injury and self-reported health and (b) compare qualitative descriptions of the self-management process and outcome between high and low self-efficacy groups. In this cross-sectional convergent mixed methods study, 31 adults aged 45 to 72 with a unilateral DRF completed patient-reported outcome measures and a semi-structured interview 2 to 4 weeks after discontinuing full-time wrist immobilization. Higher self-efficacy was moderately associated with better physical, mental, and social health. The High-Self-Efficacy group described self-directed behaviors to manage injury sequelae and more confidence in their ability to use their injured hand. They also described less disruptive physical and emotional symptoms and fewer participation restrictions compared with the Low-Self-Efficacy group. Findings suggest that occupational therapy practitioners should assess and address self-efficacy for managing DRF sequelae to support recovery.
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Fracturas del Radio , Fracturas de la Muñeca , Adulto , Humanos , Fracturas del Radio/diagnóstico , Fracturas del Radio/psicología , Fracturas del Radio/terapia , Autoeficacia , Estudios Transversales , ManoRESUMEN
BACKGROUND: This prospective study identified the association of demographic, injury, psychological, and social variables, measured early during recovery, with limitations in function (measured by the Patient-Reported Outcomes Measurement Information System Upper Extremity Physical Function Computer Adaptive Test [PROMIS UE]) at 6 to 9 months after a distal radial fracture. Additionally, we assessed variables associated with the PROMIS UE; the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH); the Patient-Rated Wrist Evaluation (PRWE); and the 3-Level EuroQol 5 Dimensions Index (EQ-5D-3L) over time. METHODS: A total of 364 adult patients (73% female), with a median age of 65 years (interquartile range, 45.5 to 77 years), who sustained an isolated distal radial fracture completed questionnaires at 3 time periods after the fracture: within 1 week, between 2 and 4 weeks, and between 6 and 9 months. We created a multivariable regression model and a generalized least squares random effects model, accounting for multicollinearity using correlation matrices, the variable inflation factor, and the partial R. RESULTS: Multiple variables within a week of the injury correlated with 6 to 9-month limitations in bivariate analysis. Being retired (partial R = 0.19; p < 0.001), using opioids after the fracture (partial R = 0.04; p < 0.001), using antidepressants (partial R = 0.11; p < 0.001), greater pain interference (partial R = 0.03; p = 0.001), and greater pain catastrophization (partial R = 0.04; p = 0.002) within 1 week of the injury were strong predictors of greater limitations (PROMIS UE) at 6 to 9 months in multivariable analysis. Longitudinal analysis of variables over time demonstrated greater pain interference, greater fear of movement, lower self-efficacy, older age, and female sex as strong predictors of limitations. CONCLUSIONS: Recovery from a distal radial fracture is influenced by a series of demographic, psychological, and social variables. Of these factors, being retired, using opioids, using antidepressants, greater pain interference, and greater pain catastrophization within a week of the injury explain the largest amounts of unique variance in self-perceived upper-extremity physical function. Evaluating the impact of change in variables over time underlined the influence of pain interference as well as the influence of fear of movement and self-efficacy (or resiliency) on limitations in physical function and general health. These findings have important implications for identifying individuals who can benefit from behavioral interventions for these psychological factors to optimize recovery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Curación de Fractura/fisiología , Dolor/psicología , Fracturas del Radio/psicología , Recuperación de la Función/fisiología , Autoeficacia , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/uso terapéutico , Catastrofización/psicología , Empleo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/tratamiento farmacológico , Fracturas del Radio/fisiopatología , Factores Sexuales , Factores Sociales , Encuestas y CuestionariosRESUMEN
STUDY DESIGN: A prospective cohort single-center study. INTRODUCTION: Self-efficacy (SE) refers to beliefs in ones capabilities to organize and execute the courses of action required to produce given goals. High SE is an important factor for recovery from injury/illness; people who believe in their capability will more likely reach a good outcome. PURPOSE OF THE STUDY: The aim of this study was to examine if SE has an effect to physical functioning, pain and patient-rated wrist function three months postoperatively in patients undergoing plating due to a distal radius fracture. METHODS: Sixty-seven patients undergoing plating for a distal radius fracture rated SE at the first appointment with the physiotherapist. At the three-month follow-up, the following assessments were administered: Patient-Rated Wrist Evaluation (PRWE), pain-scores, hand grip strength, and range of motion. RESULTS: The group with a high SE showed significantly better range of motion for flexion (P = .046) and supination (P = .045), hand grip strength (P = .001) and PRWE scores (P = .04). The NRS pain during activity was lower, although not significantly lower (P = .09). Using Spearman's rank correlation coefficient, there was a moderate correlation between SE and pain during activity, wrist flexion, and PRWE score. DISCUSSION: SE corresponds to wrist function after combined plating of distal radius fractures. CONCLUSION: Measurement of SE could possibly be useful to identify patients in special need of support during the postoperative rehabilitation.
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Placas Óseas , Fijación Interna de Fracturas , Fracturas del Radio/psicología , Fracturas del Radio/cirugía , Autoeficacia , Articulación de la Muñeca/fisiopatología , Adulto , Anciano , Femenino , Fuerza de la Mano , Humanos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Pronación , Estudios Prospectivos , Fracturas del Radio/rehabilitación , Rango del Movimiento Articular , Recuperación de la Función , Supinación , Resultado del TratamientoRESUMEN
AIMS: Patient engagement in adaptive health behaviours and interactions with their healthcare ecosystem can be measured using self-reported instruments, such as the Patient Activation Measure (PAM-13) and the Effective Consumer Scale (ECS-17). Few studies have investigated the influence of patient engagement on limitations (patient-reported outcome measures (PROMs)) and patient-reported experience measures (PREMs). First, we assessed whether patient engagement (PAM-13, ECS-17) within two to four weeks of an upper limb fracture was associated with limitations (the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and Patient-Reported Outcome Measurement Information System Upper Extremity Physical Function computer adaptive test (PROMIS UE PF) scores) measured six to nine months after fracture, accounting for demographic, clinical, and psychosocial factors. Secondly, we assessed the association between patient engagement and experience (numerical rating scale for satisfaction with care (NRS-C) and satisfaction with services (NRS-S) six to nine months after fracture. METHODS: A total of 744 adults with an isolated fracture of the proximal humerus, elbow, or distal radius completed PROMs. Due to multicollinearity of patient engagement and psychosocial variables, we generated a single variable combining measures of engagement and psychosocial factors using factor analysis. We then performed multivariable analysis with p < 0.10 on bivariate analysis. RESULTS: Patient engagement and psychosocial factors combined to form a single factor (factor 1) accounting for 20% (QuickDASH, semi-partial R2 = 0.20) and 14% (PROMIS UE PF, semi-partial R2 = 0.14) of the variation in limitations six to nine months after fracture. Factor 1 also accounted for 17% (NRS-C, semi-partial R2 = 0.17) of variation in satisfaction with care, and 21% (NRS-S, semi-partial R2 = 0.21) of variation in satisfaction with services. Demographic factors (age, sex, work status) and measures of greater pathophysiology (type of fracture, high-energy injury, post-surgical complications), accounted for much less variation. CONCLUSION: Patients who actively manage their health and demonstrate effective emotional and social functioning share a common underlying trait. They have fewer limitations and greater satisfaction with care during recovery from upper limb fractures. Future efforts should focus on evaluating initiatives that optimize patient engagement, such as patient education, coaching, and a communication strategy for healthcare professionals. Cite this article: Bone Joint J 2020;102-B(1):42-47.
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Lesiones de Codo , Conductas Relacionadas con la Salud , Fracturas del Húmero/cirugía , Fracturas Intraarticulares/cirugía , Participación del Paciente , Fracturas del Radio/cirugía , Actividades Cotidianas , Adaptación Psicológica , Adulto , Anciano , Anciano de 80 o más Años , Articulación del Codo/cirugía , Femenino , Fracturas Óseas , Promoción de la Salud , Humanos , Fracturas del Húmero/psicología , Fracturas Intraarticulares/psicología , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente , Estudios Prospectivos , Fracturas del Radio/psicología , Autoeficacia , Factores Socioeconómicos , Encuestas y Cuestionarios , Adulto JovenAsunto(s)
Síndromes de Dolor Regional Complejo/fisiopatología , Síndromes de Dolor Regional Complejo/psicología , Miedo , Extremidad Superior/fisiopatología , Adulto , Anciano , Evaluación de la Discapacidad , Femenino , Lateralidad Funcional , Humanos , Cinestesia , Persona de Mediana Edad , Movimiento , Desempeño Psicomotor , Fracturas del Radio/fisiopatología , Fracturas del Radio/psicología , Fracturas del Radio/cirugía , Pulgar/lesiones , Pulgar/fisiopatologíaRESUMEN
BACKGROUND: Distal radius fractures (DRFs) are common and can lead to substantial pain and disability. Most people recover in six months, but some experience persistent pain and disability for one year or longer after injury. Therefore, it is important to understand the factors that can help predict poor recovery. OBJECTIVE: To identify recovery trajectories in DRF patients and to determine the factors that can help predict poor recovery. METHODS: Recovery was assessed in 318 patients using the Patient-Rated Wrist Evaluation scale at baseline, three, six, and 12 months. Demographic information was collected in addition to the Self-Administered Comorbidity Questionnaire, from which data regarding depression were extracted. Latent growth curve analysis (LGCA) was used to identify the recovery trajectories. Comparisons of proportion between the emergent classes were then conducted using chi-square and Kruskal-Wallis tests. RESULTS: The LGCA revealed three distinct trajectories (rapid-recovery: (69%), slow-recovery: (23%), and non-recovery: (8%) as the best fit to the data. The proportion of people with depression was significantly greater in the non-recovery class (24%) compared to the slow (16%, pâ¯=â¯0.04) and rapid-recovery (8%, pâ¯=â¯0.03) classes. Additionally, the proportion of females were significantly lower in the non-recovery (64%, pâ¯=â¯0.03) compared to the slow (85%, pâ¯=â¯0.03) and the rapid-recovery classes (81%, pâ¯=â¯0.048). CONCLUSION: Recovery from DRF was best described using three different trajectories. Greater self-reported depression and a lower proportion of females in the non-recovery class were distinguishing factors between the classes. Patients who appear to be in slow-recovery or non-recovery classes may be followed more closely.
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Depresión/complicaciones , Fracturas del Radio/fisiopatología , Fracturas del Radio/psicología , Recuperación de la Función/fisiología , Femenino , Humanos , Análisis de Clases Latentes , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Encuestas y CuestionariosRESUMEN
BACKGROUND: Although impaired postural control may be a risk factor for distal radius fractures (wrist fractures), which often are caused by falls, little attention has been given thus far to the various performance and neurophysiologic aspects involved. Although studies suggest that external focus and cognitive tasks can improve postural control, it remains unclear whether these benefits are observed in individuals with a history of distal radius fracture and to what extent. QUESTIONS/PURPOSES: (1) To compare patients with a history of distal radius fracture to age- and sex-matched controls in terms of postural stability while standing on stable and unstable support surfaces, using both postural sway and neurophysiological measures as endpoints; and (2) to determine whether internal- and external-focus strategies and cognitive tasks can improve postural stability in these patients. METHODS: Forty patients with distal radius fracture (33 females and seven males with a mean ± SD age of 56 ± 4 years) and 40 sex- and age-matched control participants participated in the study. We recruited patients with a history of fall-induced distal radius fractures occurring between 6 and 24 months before the start of our study. We excluded patients who had any of the following: fear of falling, taking any medication that may affect balance, neurologic disorders, dizziness, vestibular problems, Type II diabetes, musculoskeletal disorders or recent history of lower extremity fracture, any recent surgical interventions in the spine or lower limbs, and/or cognitive impairment. Of 120 patients who were being treated for distal radius fracture over the 18-month period, 91 (76%) agreed to participate and 40 eligible patients were finally enrolled. The control group included sex- and age-matched (within 2-year intervals) individuals who had never had a wrist fracture. This group was selected from attendants/relatives of the patients attending the neurology and physical medicine and rehabilitation outpatient departments, as well as other volunteers with no history of balance problems or wrist fractures. To address our primary research question, we compared the postural control of individuals with a history of distal radius fracture with the control group while quietly standing on different support surfaces (rigid and foam surfaces) using both postural sway measures obtained by a force plate as well as neurophysiological measures (electromyography [EMG] activity of tibialis anterior and medial gastrocnemius). To address our secondary research question, we compared the postural sway measures and EMG activity of the ankle muscles between different experimental conditions (baseline, internal focus (mentally focusing on their feet without looking), external focus (mentally focusing on rectangular papers, placed on the force plate or foam, one under each foot), difficult cognitive task (recalling maximum backward digits plus one) and easy cognitive task (recalling half of the maximum backward digits). RESULTS: Patients with distal radius fractures presented with greater postural sway (postural instability) and enhanced ankle muscle activity compared with their control counterparts, but only while standing on a foam surface (mean velocity: 5.4 ± 0.8 versus 4.80 ± 0.5 [mean difference = 0.59, 95% CI of difference, 0.44-0.73; p < 0.001]; EMG root mean square of the tibialis anterior: 52.2 ± 9.4 versus 39.30 ± 6 [mean difference = 12.9, 95% CI of difference, 11.4-14.5; p < 0.001]). Furthermore, a decrease in postural sway was observed while standing on both rigid and foam surfaces during the external focus, easy cognitive, and difficult cognitive conditions compared with the baseline (for example, mean velocity in the baseline condition compared with external focus, easy cognitive task and difficult cognitive task was: 4.9 ± 1.1 vs 4.7 ± 1 [mean difference = 0.14, 95% CI of difference, 0.11-0.17; p < 0.001], 4.6 ± 1 [mean difference = 0.25, 95% CI of difference, 0.21-0.29; p < 0.001], and 4.5 ± 1 [mean difference = 0.34, 95% CI of difference, 0.29-0.40; p < 0.001] in the wrist fracture group). The same result was obtained for muscle activity while standing on foam (EMG root mean square of tibialis anterior in the baseline condition compared with external focus, easy cognitive task and difficult cognitive task: 58.8 ± 7.2 versus 52.3 ± 6.6 [mean difference = 6.5, 95% CI of difference, 5.5-7.6; p < 0.001], 48.8 ± 7.1 [mean difference = 10.1, 95% CI of difference, 9-11.1; p < 0.001], 42.2 ± 5.3 [mean difference = 16.7 95% CI of difference, 15.1-18.2; p < 0.001] in the wrist fracture group). CONCLUSIONS: The current results suggest that patients with a history of distal radius fractures have postural instability while standing on unstable support surfaces. This instability, which is associated with enhanced ankle muscle activity, conceivably signifying an inefficient cautious mode of postural control, is alleviated by external attention demands and concurrent cognitive tasks. CLINICAL RELEVANCE: The findings of this study may serve as a basis for designing informed patient-specific balance rehabilitation programs and strategies to improve stability and minimize falls in patients with distal radius fractures. The integrative methodology presented in this work can be extended to postural control and balance assessment for various orthopaedic/neurological conditions.
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Cognición , Equilibrio Postural , Fracturas del Radio/psicología , Trastornos de la Sensación/psicología , Análisis y Desempeño de Tareas , Tobillo/fisiopatología , Atención , Estudios de Casos y Controles , Electromiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Músculo Esquelético/fisiopatología , Fracturas del Radio/fisiopatología , Fracturas del Radio/terapia , Trastornos de la Sensación/fisiopatología , Trastornos de la Sensación/terapiaRESUMEN
OBJECTIVE: To evaluate the influence of pain sensitization in the early recovery of distal radius fractures (DRFs) on the occurrence and prognosis of complex regional pain syndrome (CRPS) type I. METHODS: We enrolled 58 patients who were diagnosed with CRPS I based on Budapest criteria within six months after sustaining DRF; they were age- and gender-matched with 58 patients with DRF who did not have CRPS I. We commonly measured patients' pressure pain thresholds (PPTs) in the forearm and administered a Pain Sensitivity Questionnaire (PSQ) when patients complained of pain with numeric rating scale ≥4 at three-month follow-up. Participants were followed up three, six, and 12 months after injury, and the symptoms and sign of CRPS were evaluated at each follow-up. RESULTS: Patients with CRPS I were more likely to have sustained high-energy injuries, had severe fractures, and had significantly higher PSQ scores and lower PPTs than the age- and gender-matched controls. At 12 months after injury, CRPS symptoms improved in 52% (30/58) of patients who had been diagnosed with CRPS I at three months after injury. The initial degree of pain sensitization and high-energy injury were associated with persistence of CRPS symptoms up to 12 months after initial injury. CONCLUSIONS: Patients with CRPS I after DRF exhibited significantly higher pain sensitization in the early post-trauma period, and the degree of initial pain sensitization and high-energy injuries were associated with prolonged CRPS I signs and symptoms up to one year after initial injury.
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Síndromes de Dolor Regional Complejo/diagnóstico , Dimensión del Dolor/métodos , Umbral del Dolor/fisiología , Fracturas del Radio/diagnóstico , Recuperación de la Función/fisiología , Adulto , Anciano , Síndromes de Dolor Regional Complejo/etiología , Síndromes de Dolor Regional Complejo/psicología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Umbral del Dolor/psicología , Pronóstico , Fracturas del Radio/complicaciones , Fracturas del Radio/psicologíaRESUMEN
BACKGROUND: Distal radius fractures (DRF) account for nearly one-fifth of all fractures in older adults, and women experience them 5× as often as men. Most DRF occur with low impact injuries to the wrist with an outstretched hand, and are often managed via closed treatment and cast immobilization. Women sustaining a DRF are at risk for upper limb immobility, sensorimotor changes, edema and type I complex regional pain syndrome (CRPS). Since CRPS onset is likely influenced by alterations in the brain's somatosensory region, a rehabilitation intervention, Graded Motor Imagery (GMI), aims to restore cortical representation, including sensory and motor function, of the affected limb. To date, there are no studies on the use of GMI in reducing risk of or preventing the onset of type I CRPS in women with DRF treated with cast immobilization. Due to a higher likelihood of women with this injury developing type I CRPS, it is important to early intervention is needed. METHODS/DESIGN: This article describes a six-week randomized comparative effectiveness trial, where the outcomes of a modified GMI program (mGMI) + standard of care (SOC) group (n = 33) are compared to a SOC only control group (n = 33). Immediately following cast immobilization, both groups participate in four 1-h clinic-based sessions, and a home program for 10 min three times daily until cast removal. Blinded assessments occur within 1 week of cast immobilization (baseline), at three weeks post cast immbolization, cast removal, and at three months post cast removal. The primary outcomes are patient reported wrist/hand function and symptomology on the Patient Rated Wristand Hand Evaluation, McGill Pain Questionnaire, and Budapest CRPS Criteria. The secondary outcomes are grip strength, active range of motion as per goniometry, circumferential edema measurements, and joint position sense. DISCUSSION: This study will investigate the early effects of mGMI + SOC hand therapy compared to SOC alone. We intend to investigate whether an intervention, specifically mGMI, used to treat preexisiting pain and motor dysfunction might also be used to mitigate these problems prior to their onset. If positive effects are observed, mGMI + SOC may be considered for incorporation into early rehabilitation program. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov with identifier NCT02957240 (Approval date: April 20, 2017).
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Imágenes en Psicoterapia/métodos , Movimiento/fisiología , Fracturas del Radio/psicología , Fracturas del Radio/terapia , Distrofia Simpática Refleja/psicología , Distrofia Simpática Refleja/terapia , Método Doble Ciego , Femenino , Humanos , Fracturas del Radio/complicaciones , Distrofia Simpática Refleja/etiología , Resultado del TratamientoRESUMEN
We investigated the relationship between pain and hesitation during movement initiation among 11 adult female patients who had undergone surgery for a distal radius fracture. Data on the patients' pain at rest, pain during movement and score on the Pain Catastrophizing Scale were analyzed. Movement characteristics were assessed by the administration of a finger tapping (FT) task using the thumb and index finger, with the movement repeated 10 times, recorded and analyzed to determine the patient's hesitation when opening or closing her thumb/forefinger during the task. Hesitation of movement initiation was significantly correlated with subjective factors such as pain at rest, pain during movement, and rumination. Pain was not significantly correlated with the physical range of motion. Our findings suggest that hesitation during movement initiation for the FT task may be a type of behavior that is affected by subjective pain. Movement hesitation is a novel clinical sign indicating the possible progression of acute pain into chronic pain. The kinematic evaluation described herein is a convenient clinical measurement that captures a subjective factor.
Asunto(s)
Movimiento/fisiología , Dolor/psicología , Fracturas del Radio/psicología , Anciano , Femenino , Fijación de Fractura , Humanos , Dolor/fisiopatología , Periodo Posoperatorio , Fracturas del Radio/fisiopatología , Fracturas del Radio/cirugía , Escala Visual AnalógicaRESUMEN
OBJECTIVE: To investigate patients' experience following wrist fracture, surgical repair and immobilization. DESIGN: A qualitative investigation involving individual participant interviews. SETTING: A metropolitan trauma service. SUBJECTS: In all, 31 participants were consecutively recruited from three groups within a randomized controlled trial comparing immobilization for one ( n = 11), three ( n = 10) or six weeks ( n = 10) following surgical treatment for wrist fracture. INTERVENTION: Individual interviews were conducted within three months of cast removal. Questions prompted discussion of the experience of fracture, surgery and immobilization. Interviews were audio-recorded, transcribed verbatim. At least two independent researchers performed coding and theming following principles of thematic analysis. RESULTS: Two themes were identified: (1) impact of the injury varies widely and (2) health care consumers want trustworthy dialogue. Participant reports indicated that recovery from wrist fracture, surgery and immobilization is challenging with significant changes to social role and increased dependence. For many, lack of empathy from health professionals and limited acknowledgement of the personal impact of injury led to dissatisfaction. Health professionals did not consistently tailor communication or adopt strategies to address specific needs for pain management, education and support requirements. There was no evidence that processes were implemented to enhance participant recall and comprehension. Most participants experienced their cast as a barrier to function. However, within the group of participants immobilized for one week, a number felt the cast was removed too soon. CONCLUSION: Participant reports indicate that recovery from surgically repaired wrist fracture is challenging. Opportunities exist to refine care in pain management, education and active engagement of patients in their care.
Asunto(s)
Moldes Quirúrgicos , Inmovilización , Fracturas del Radio/psicología , Traumatismos de la Muñeca/psicología , Adulto , Femenino , Humanos , Entrevistas como Asunto , Masculino , Cuidados Posoperatorios , Relaciones Profesional-Paciente , Fracturas del Radio/terapia , Rol , Traumatismos de la Muñeca/terapiaRESUMEN
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 (ß = 0.2, p = 0.009), less dorsal tilt (ß = 0.2, p = 0.035), and nonoperative treatment (ß = 0.2, p = 0.027). Improved NRS pain scores were associated with nonoperative treatment (ß = 0.2, p = 0.021) and no posttraumatic stress disorder (PTSD) (ß = 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 (ß = 0.3, p < 0.001) and lower enrollment PTSD (ß = 0.3, p < 0.011). Lower NRS pain scores at 6 months were associated with having fewer medical comorbidities (ß = 0.2, p = 0.045), lower enrollment PTSD (ß = 0.3, p = 0.008), and lower enrollment Tampa Scale for Kinesiophobia (ß = 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.
Asunto(s)
Brazo/fisiopatología , Mano/fisiopatología , Dolor Musculoesquelético/terapia , Fracturas del Radio/terapia , Autocuidado/métodos , Hombro/fisiopatología , Adaptación Psicológica , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Evaluación de la Discapacidad , Método Doble Ciego , Terapia por Ejercicio , Femenino , Estilo de Vida Saludable , Humanos , Masculino , Persona de Mediana Edad , Dolor Musculoesquelético/diagnóstico , Dolor Musculoesquelético/fisiopatología , Dolor Musculoesquelético/psicología , Dimensión del Dolor , Educación del Paciente como Asunto , Fracturas del Radio/diagnóstico , Fracturas del Radio/fisiopatología , Fracturas del Radio/psicología , Recuperación de la Función , Escocia , Autoeficacia , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
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.
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Síndromes de Dolor Regional Complejo/diagnóstico , Fibromialgia/epidemiología , Fracturas del Radio/terapia , Reclamos Administrativos en el Cuidado de la Salud , Adolescente , Adulto , Factores de Edad , Comorbilidad , Síndromes de Dolor Regional Complejo/epidemiología , Síndromes de Dolor Regional Complejo/fisiopatología , Síndromes de Dolor Regional Complejo/psicología , Bases de Datos Factuales , Femenino , Fibromialgia/diagnóstico , Fibromialgia/fisiopatología , Fibromialgia/psicología , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Fracturas del Radio/epidemiología , Fracturas del Radio/fisiopatología , Fracturas del Radio/psicología , Recuperación de la Función , Factores de Riesgo , Factores Sexuales , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenRESUMEN
Patients with inadequate health literacy, those with medical comorbidities, or those with a previous history of adverse drug events have a higher likelihood of non-adherence to osteoporosis treatment after sustaining a distal radius fracture. INTRODUCTION: Patients with a distal radial fracture (DRF) have a higher risk of subsequent fractures, which provides an important opportunity to begin treatment for osteoporosis. This study assessed the effect that health literacy of patients suffering from a DRF has on the subsequent adherence to osteoporosis treatment. METHODS: A total of 116 patients (female, over 50 years of age) presenting a DRF caused by low-energy trauma were enrolled. Their health literacy was measured using the Newest Vital Sign (NVS). Alendronate (70 mg, orally, once weekly) was prescribed to all patients for 1 year, and adherence was defined as taking at least 80% of the tablets for 12 months and returning for the visit on month 12. Multivariable analyses were conducted to determine whether the patients' clinical, demographic, and health literacy factors influenced their adherence to osteoporosis treatment. RESULTS: About half (52%) of the participants who sustained a DRF exhibited an inadequate health literacy, and the rate of non-adherence to osteoporosis treatment was 38%. The rate of non-adherence for patients with inadequate literacy was significantly higher than for those with appropriate literacy (47 vs. 29%, p = 0.04). The results of the regression analysis indicate that limited health literacy, the presence of comorbidities, and prior history of adverse drug events are associated with a higher likelihood of non-adherence to osteoporosis treatment after sustaining a DRF. CONCLUSIONS: Patients with inadequate health literacy, adverse drug events, or medical comorbidities had higher rates of non-adherence with alendronate treatment after sustaining a DRF. Further research is needed to show whether improvements in patient comprehension via informational intervention in patients with a DRF will improve adherence to osteoporosis treatment.
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Alfabetización en Salud , Osteoporosis/psicología , Cooperación del Paciente/estadística & datos numéricos , Fracturas del Radio/psicología , Anciano , Anciano de 80 o más Años , Alendronato/uso terapéutico , Conservadores de la Densidad Ósea/uso terapéutico , Comorbilidad , Femenino , Humanos , Persona de Mediana Edad , Análisis Multivariante , Osteoporosis/complicaciones , Osteoporosis/tratamiento farmacológico , Fracturas del Radio/etiología , Análisis de RegresiónRESUMEN
INTRODUCTION: Malunion occurs in approximately 23% of non-operatively treated and 11% of operatively treated distal radius fractures. The decision whether to correct a malunion is primarily based on functional impairment and wrist pain. The purpose of this study was to assess the long-term functional outcomes of corrective osteotomies for symptomatic malunited distal radius fractures. METHODS: All consecutive corrective osteotomies of the distal radius performed in one centre between January 2009 and January 2016 were included. The primary outcome was the functional outcome assessed with the Disability of the Arm, Shoulder and Hand (DASH) and the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes were range of motion, grip strength, pain as indicated on the Visual Analogue Scale (VAS) before and after corrective osteotomy, radiological parameters, time to union and complications. Additionally, we aimed to determine if there were any difference in graft versus no graft usage. RESULTS: A total of 48 patients were included. The median age was 54.5 years (IQR 39-66) and 71% was female. The median time to follow-up was 27 months. The median DASH and PRWE score were respectively 10.0 (IQR 5.8-23.3) and 18.5. (6.5-37.0). Except for pronation and supination, range of motion and grip strength of the injured wrist were significantly less compared to the uninjured side. Palmar and dorsal flexion and radial and ulnar deviation of the injured wrist were significantly less compared with the uninjured side. VAS pain scores decreased significantly from 6.5 preoperative to 1.0 postoperative. The median time to union was 23 weeks (IQR 12-29.5). Eighteen patients (38%) had a complication for which additional treatment was required. Except for a significant difference in radial inclination and length after the corrective osteotomy in favour of graft usage, there were no significant differences between graft an no graft usage. CONCLUSIONS: Corrective osteotomy is an effective method of treating symptomatic distal radius malunions with good long-term functional results, measured with the DASH and PRWE score, and improvement in radiographic parameters and pain scores. Additionally, no differences in functional outcomes were found between graft and no graft usage.