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

BACKGROUND: Symptom intensity and magnitude of limitations correlate with stress, distress, and less effective coping strategies. It is unclear if interventions to target these factors can be used to improve outcomes after distal radius fracture in either the short- or longer term. QUESTIONS/PURPOSES: (1) Are there any factors (including the use of a workbook aimed at optimizing psychological response to injury, demographic, radiographic, medical, or psychosocial) associated with improved Disabilities of the Arm, Shoulder and Hand (DASH) and Numerical Rating Scale pain (NRS pain) scores at 6 weeks after management of distal radius fracture? (2) Are any of these factors associated with improved DASH and NRS pain scores at 6 months after management of distal radius fracture? METHODS: We conducted a double-blind randomized controlled trial comparing a workbook designed to optimize rehabilitation by improving psychological response to injury using recognized psychological techniques (the LEARN technique and goal setting) versus a workbook containing details of stretching exercises in the otherwise routine management of distal radius fracture. Patients older than 18 years of age with an isolated distal radius fracture were recruited within 3 weeks of injury from a single academic teaching hospital between March and August 2016. During recruitment, 191 patients who met the inclusion criteria were approached; 52 (27%) declined participation and 139 were enrolled. Eight patients (6%) were lost to followup by 6 weeks. The remaining cohort of 129 patients was included in the analysis. DASH scores and NRS pain scores were recorded at 6 weeks and 6 months after injury. Multivariable regression analysis was used to identify factors associated with outcome scores. RESULTS: At 6 weeks after distal radius fracture, when compared with an information-only workbook, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 38 [range, 21-48]; control DASH: 35 [range, 21-53]; difference of medians: 3; p = 0.949) nor NRS pain scores (workbook NRS: 3 [range, 1-5]; control NRS: 2 [range, 1-4]; difference of medians: 1; p = 0.128). Improved DASH scores were associated with less radial shortening (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.

Self-Regulatory Processes, Motivation to Conserve Resources and Activity Levels in People With Chronic Pain: A Series of Digital N-of-1 Observational Studies.

OBJECTIVES: Motivational and self-regulatory processes during goal pursuit may account for activity patterns in people with chronic pain. This article describes a series of N-of-1 observational studies designed to investigate the influence of goal-related factors on fluctuations in motivation to conserve resources and objectively measured activity levels. METHODS: Four participants with chronic pain who attended a formal pain management program (PMP; 41-59 years old; three female) were recruited and completed digital daily diaries for 11-12 weeks. The daily dairies, delivered via text message, measured self-regulatory fatigue, goal self-efficacy, goal striving, perceived demands, pain, and motivation to conserve resources. Continuously worn accelerometers measured physical activity and sedentary time. Analyses were conducted individually for each participant. The effects of self-regulatory fatigue, goal self-efficacy, goal striving, perceived demands, and pain on motivation to conserve resources, physical activity and sedentary time were assessed with dynamic regression modeling. RESULTS: Different patterns of associations between the predictors and outcomes were observed across participants. Most associations occurred concurrently (e.g., on the same day). Perceived demand was the only variable to predict motivation to conserve resources, physical activity, and sedentary time. Motivation to conserve resources and sedentary time were most frequently predicted by goal striving and perceived demand. Self-regulatory fatigue and pain intensity both predicted motivation to conserve resources in two participants and sedentary time in one participant. Motivation to conserve resources predicted sedentary time in two participants. CONCLUSION: This study was the first to examine the impact of fluctuations in self-regulatory processes on motivation to conserve resources and objective activity levels within individuals with chronic pain. The results generally supported recent affective-motivational views of goal pursuit in chronic pain. This study demonstrated that N-of-1 observational studies can be conducted with patients during a PMP using digital technologies. The use of these approaches may facilitate the application of personalized medicine.

Psychopathology of the General Population Referred by Primary Care Physicians for Urgent Assessment in Psychiatric Hospitals.

Objective: The aim of this study was to evaluate the type, severity and progression of psychiatric pathologies in a sample of 372 outpatients (age range 18-65 years) referred by their primary general practitioners (GPs) to an Urgent Referral Team (URT) based in a psychiatric hospital in Aberdeen, Scotland. This team offers immediate appointments (1- to 7-day delays) for rapid assessments and early interventions to the outpatients referred by their primary family doctors. Method: One-sample t-test and z statistic were used for data analysis. From the total population, a convenience sample of 40 people was selected and assessed to evaluate whether follow-up appointments after the first visit could reduce the severity of suicidal ideation, depression and anxiety in the outpatients seen by the URT. A two-sample t-test and a Wilcoxon signed-rank test were used to assess the variations in the scores during the follow-up visits. Results: We found a statistically significant prevalence of depressive disorders, comorbid with anxiety at first presentation in people who were females, white, never married, living with a partner, not studying and not in paid employment. The common presentation of borderline personality disorder and dysthymia in this population underscores its vulnerability to major socioeconomic challenges. Conclusion: The data confirmed the impact that primary care cooperation with psychiatric hospitals can have on the psychiatric system, and as a reflection, on the population's mental health and well-being. In fact, active cooperation and early diagnosis and intervention will help detect cases at risk in the general population and reduce admissions into hospitals.