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The relationship between depression, anxiety, and pain interference with therapy referral and utilization among patients with hand conditions

Published:October 14, 2020DOI:https://doi.org/10.1016/j.jht.2020.10.006

      Highlights

      • Patient baseline levels of depressive symptoms and anxiety do not predict physician referral to hand therapy.
      • Patients with increased depressive symptoms, anxiety, and pain interference require more therapy visits to achieve functional recovery.
      • Mental health status should be considered during hand therapy treatment planning.

      Abstract

      Introduction

      Patients with upper extremity conditions may also experience symptoms of depression, anxiety, and pain that limit functional recovery.

      Purpose of the Study

      This study examined the impact of mental health and pain symptoms on referral rates to therapy and utilization of therapy services to achieve functional recovery among patients with common hand conditions.

      Study Design

      This is a retrospective cohort study of patients from one orthopedic center.

      Methods

      Data extraction provided demographics, the International Classification of Diseases, 10th revision diagnoses, therapy referral, therapy visit counts, treatment goal attainment, and Patient-Reported Outcomes Measurement Information System (PROMIS) Depression, Anxiety, and Pain Interference scores. The chi-square test, t-test, and logistic regression analyses assessed associations between baseline PROMIS depression, anxiety, and pain interference to therapy referral, the number of therapy visits, and goal attainment.

      Results

      Forty-nine percent (172/351) of patients were referred to hand therapy. There was no relationship between three baseline PROMIS scores based on physician referral (t-test P values .32-.67) and no association between PROMIS scores and therapy utilization or goal attainment (Pearson correlation (r): 0.002 to 0.020, P > .05). Referral to therapy was most strongly associated with having a traumatic condition (P < .01). Patients with high depression, anxiety, and pain interference scores on average required one more therapy visit to achieve treatment goals (average visits: 3.7 vs 3.1; 4.1 vs 2.7; 3.4 vs 2.3, respectively). Fewer patients with high depression scores (50%) achieved their long-term goals than patients with low depression scores (69%, P = .20).

      Conclusions

      Patients' baseline level of depressive symptoms and anxiety do not predict referrals to hand therapy by orthopedic hand surgeons. There is some indication that patients with increased depressive symptoms, anxiety, and pain interference require more therapy with fewer achieving all goals, suggesting that mental health status may affect response to therapy. Therapists may address mental health needs in treatment plans. Future studies should examine if nonreferred patients with depressive symptoms achieve maximal functional recovery.

      Keywords

      Introduction

      Depressive symptoms and anxiety affect physical outcomes and perceived disability in patients presenting with and treated for hand conditions.
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      it is unclear how patients' mental health and pain experience influence the need for and utilization of hand therapy services among those seeking specialty hand care. The first aim of this study was to determine if patients' depressive symptoms, anxiety, and pain interference (quantified by PROMIS scores) influenced the likelihood of referral to hand therapy by hand surgeons to achieve the treatment goals of maximum functional recovery from their hand condition. The second aim was to assess the association between patients' depressive symptoms, anxiety, and pain interference on both the utilization of therapy services and the rate of achieving functional goals before discharge from hand therapy.

      Methods

      Study sample

      This retrospective cohort study analyzed electronic health data from patients presenting to a tertiary hand center (Washingon University School of Medicine, Department of Orthopedic Surgery), between April 21, 2016 and November 22, 2017. All records received a waiver of written consent through the Washington University in St. Louis Institutional Review Board. Patients identified with at least one of seven common hand diagnoses from the International Classification of Diseases, 10th revision (ICD-10) codes met inclusion criteria. Patients were assigned to nontraumatic condition if diagnosed with ICD-10 codes for carpal tunnel syndrome (G56.00-56.03, R20.0, R20.2), cubital tunnel syndrome (G56.20-56.23 R20.0, R20.2), De Quervain's tenosynovitis (M65.4, M77.8), or trapeziometacarpal arthritis (M18.0-18.5, M18.9). Patients were assigned to the traumatic injury condition if diagnosed with distal radius fracture (S52.5), metacarpal fracture, or phalanx fracture (S62.2-62.3, S62.5-62.6).
      One of the treating orthopedic upper extremity surgeons (author RC) selected the qualifying diagnoses based on the large volume of patients seen for these conditions, the potential for therapy referral, and the need for multiple therapy appointments. Qualifying patients in the query had one or more appointments with one of six orthopedic upper extremity surgeons within the study time frame and had an ICD-10 code from the included study diagnoses at any time point. Patients were excluded from our study's data extraction if they were aged 18 years or younger, did not have PROMIS data for any appointment, did not have a PROMIS score for any appointment within 60 days of the first visit with diagnosis of inclusion criteria, and if they did not have a new patient appointment code within the study time frame. Patient visits with a six-month lag or greater from a previous visit and all subsequent visits for the same diagnosis were excluded from analysis. This was due to the possibility that the patient could be presenting for a new condition. Qualifying patients' institutional electronic medical records were queried to obtain patient medical record numbers, date of birth, sex, race, home nine-digit zip code, appointment information, PROMIS data, ICD-10 codes, and Current Procedural Terminology codes. The Current Procedural Terminology code 99204 identified patients who underwent surgery (postoperative follow-up visit). We used the area deprivation index (ADI) derived from the nine-digit home zip codes to quantify socioeconomic deprivation based on a national percentile.
      2000 area deprivation index.
      The ADI uses measures of income, education, employment, and housing quality to assign a national percentile of socioeconomic deprivation to neighborhoods. Patients with both traumatic and nontraumatic ICD-10 codes were assigned to the traumatic category for analysis. In addition, on a randomly selected subset of patients, we conducted a manual chart review and data extraction from the electronic medical record to obtain medical and social history details. The manual review extracted data from the orthopedic and comprehensive health history questionnaires including past diagnosis of depression and taking medication for depression, physician therapy referral scans, and documentation from therapists including the number of therapy visits attended and the therapist-recorded therapy goal achievement at the hand therapy department of the orthopedic center. The short- and long-term goals were set at the initial patient visit to therapy by the therapist, and goal achievement was documented in each therapy session note. All study data were managed using the REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Washington University in St. Louis. REDCap is a secure, web-based application designed to support data capture for research studies.
      • Harris P.A.
      • Taylor R.
      • Thielke R.
      • Payne J.
      • Gonzalez N.
      • Conde J.G.
      Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.

      Predictor and outcome measures

      At the time of check-in for each appointment with an orthopedic upper extremity surgeon, patients received an iPad (iPad mini; Apple, Cupertino, CA) preloaded with five electronic modules: PROMIS Anxiety v1.0, Depression v1.0, Physical Function v1.2 and v2.0, Upper Extremity Physical Function v1.2 and 2.0, and Pain Interference v1.
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      The software platform does not allow patients to skip questions and uses computer adaptive testing to provide domain-specific items to ascertain a relevant score. Only fully completed PROMIS computer adaptive testing scores were exported into the electronic medical record. PROMIS scores follow a normal population distribution with a mean “T” score of 50 and a standard deviation of 10.
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      A higher PROMIS score indicates more of the health domain, where a higher depression score indicates more reported symptoms of depression and a higher physical function score indicates more, or better, reported function. We used the modules of PROMIS depression, anxiety, and pain interference as predictors in separate models. We adjusted models for potential confounders including age, sex, race, and ADI.

      Therapy data extraction

      Lacking relevant information about therapy referral rates for an a priori sample size calculation, we initially randomly selected forty patients from each of six diagnostic group for data extraction. Patients with metacarpal or phalanx fracture diagnoses were combined into a single group. An interim data review of 200 patients showed nearly 50% of the patient sample were referred to therapy. We extracted an additional twenty patients per category and found the additional cases did not find a change in the referral rate (50% referred to therapy) so assumed the sample adequately captured the referral pattern and proceeded to analysis with fifty-nine patients in each of the six diagnostic groups (n = 351 patients with complete data). For the final data set, eligible patients must have at least one of the six diagnostic ICD-10 codes and have PROMIS data within 60 days of their initial visit; 351 patients met eligibility criteria. Our outcomes for analysis were as follows: (1) referral to therapy, (2) the number of therapy treatments, and (3) attainment of therapy goals.
      Two authors (SC and AMD) independently extracted data from electronic records on a sample of patients (n = 42); the intrarater reliability result (two-way effects model with absolute agreement) was 0.954 (n = 256 items), so one author (S.K.C.) extracted data from the remaining patient records. For analysis, we counted each patient referred to therapy by the orthopedic upper extremity surgeon in the total number of referrals. We examined the number of therapy visits only from the patients treated at the outpatient hand clinic of the orthopedic center, so these data were on a subset of patients referred to therapy.

      Data analysis

      First, we examined the differences in referral to therapy by several demographics (age, sex, ADI, race), history of depression or taking medications for depression, type of condition (traumatic and nontraumatic by ICD-10 codes) and surgical intervention, and by PROMIS measures as continuous and dichotomous scores using independent samples t-test and Pearson chi-square analysis (grouped by referral status). We dichotomized the PROMIS scores at clinically meaningful thresholds. The PROMIS anxiety score threshold of 62.3 or above indicated patients affected by heightened anxiety, based on a correspondence to a Generalized Anxiety Disorder-7 score in an orthopedic population.
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      ,
      Appendix table 34: raw score to T-score conversion table (IRT fixed parameter calibration linking) for GAD-7 to PROMIS anxiety.
      PROMIS depression score threshold of 59.9 was used to categorize patients affected and unaffected by heightened depression, based on a Patient Health Questionnaire-9 score for moderate depression in an orthopedic population.
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      ,
      Appendix table 46: raw score to T-score conversion table (IRT fixed parameter calibration linking) for PHQ-9 to PROMIS depression.
      PROMIS pain interference scores dichotomized at a threshold of 60.0 correspond to one standard deviation greater than the population mean score. Then, we conducted separate multivariable logistic regression models to assess the effects of depression, anxiety, or pain interference on physician referral to therapy, adjusting for the covariates that have been associated with functional performance in past studies (age, sex, race, social deprivation using the ADI score, and the type of condition [traumatic or nontraumatic]).
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      For the subset of patients who attended the hand therapy clinic of the orthopedic center, we examined the number of therapy visits based on patients with high baseline PROMIS scores determined using clinically meaningful thresholds. We also examined the proportion of patients within this subset that met their therapy treatment goals. Therapy goals were defined by treating therapists at initial visits based on individual patient conditions and symptoms. Therapy goal attainment was determined if short-term and/or long-term goals were labeled “achieved” on the discharge report. All analyses were conducted using SPSS software (version 23, IBM Corporation, Armonk, New York).

      Results

      The sample of 351 patients was predominately Caucasian and female (Table 1). They had a mean age of 53 years (SD 17) and a mean ADI of 46 (SD 27). One-third of patients had a diagnosis of a traumatic condition. Nineteen percent had more than one diagnosis. The seven patients with a concurrent nontraumatic and traumatic diagnosis were classified as traumatic cases for the analysis. Nearly one-third of the patient sample underwent a surgical procedure, and only 64% of the postsurgical patients were referred to therapy. Baseline PROMIS scores were close to population norm values for anxiety (mean 52, SD 11) and depression (mean 46, SD 10) but poorer for pain interference (mean 61, SD 7) scores. Overall, 11% of patients had PROMIS scores that met or exceeded the clinically relevant threshold for high depression and 17% for high anxiety, whereas 56% of patients had high pain interference scores. Pearson correlation analysis between mental health and pain variables to therapy utilization and goal achievement was low (r value: 0.002-0.20), and none reached statistical significance (P values: .987-.053). The strongest association was found for pain interference to goal attainment (r = 0.2; P = .053). Of the 39 patients with high PROMIS depression scores, half of them reported a past diagnosis of depression and one-quarter of them reported taking medication for depression.
      Table 1Demographics and test for differences in characteristics among those referred and not referred for therapy (n = 351)
      VariableOverall sampleReferred to therapy (n = 172)Not referred to therapy (n = 179)P-value
      Test for difference between referred and not referred by the chi-square test for characteristics and independent samples t-test for baseline PROMIS scores.
      n (%)n (%)n (%)
      Female209 (59.54)102 (59.3)107 (59.8).93
      Age (55 y or more)183 (52.1)90 (52.3)93 (52.0).95
      Area deprivation index (50 or more)131 (42.4)65 (41.4)66 (43.4).72
      Race.03
       African-American42 (11.97)17 (9.9)25 (14.0).24
       Caucasian/white295 (84.05)152 (88.4)143 (79.9).03
       Other
      Other races: multiracial, Native American/Alaskan Native, Asian, other.
      12 (3.4)2 (1.2)10 (5.6).02
      Type of condition/diagnoses
      For analysis, patients with both a traumatic diagnosis and a nontraumatic diagnosis were assigned to the traumatic diagnosis group.
      <.001
       Nontraumatic233 (66.4)92 (53.5)141 (78.8)
      CTS91 (39.1)37 (40.2)54 (38.3).77
      CTS71 (30.5)36 (39.1)35 (24.8).02
      DEQ64 (27.5)18 (19.6)46 (32.6).03
      TMC64 (27.5)40 (43.5)24 (17.0)<.001
       Traumatic118 (33.6)80 (46.5)38 (21.2)
      DRF60 (50.8)37 (46.3)23 (60.5).15
      MPF58 (49.2)43 (53.8)15 (39.5).15
      Surgical intervention
      Surgical Current Procedural Terminology (CPT) code 99024 (postoperative follow-up visit).
      107 (30.48)69 (40.1)38 (21.2)<.001
      Self-reported depression62 (17.7)26 (15.1)36 (20.1).22
      On meds for depression36 (10.3)21 (12.2)15 (8.4).24
      Baseline PROMIS scores(Mean/SD)(Mean/SD)(Mean/SD)P value
      Test for difference between referred and not referred by the chi-square test for characteristics and independent samples t-test for baseline PROMIS scores.
      Depression score46.40 (10.27)46.96 (10.11)45.86 (10.42).32
      Anxiety score51.74 (10.99)52.27 (11.0)51.23 (10.98).38
      Pain interference score60.47 (7.38)60.64 (7.68)60.31 (7.09).67
      PROMIS = Patient-Reported Outcomes Measurement Information System.
      Missing data: area deprivation index = 42; race = 2.
      ADI: area deprivation index—Higher index values represent higher levels of socioeconomic deprivation; CTS: carpal tunnel syndrome; DEQ: deQuervains tendosynovitis; DRF: distal radius fracture; MRF: metacarpal fracture; TMC: trapexiometacarpal arthritis.
      a For analysis, patients with both a traumatic diagnosis and a nontraumatic diagnosis were assigned to the traumatic diagnosis group.
      b Other races: multiracial, Native American/Alaskan Native, Asian, other.
      c Surgical Current Procedural Terminology (CPT) code 99024 (postoperative follow-up visit).
      d Test for difference between referred and not referred by the chi-square test for characteristics and independent samples t-test for baseline PROMIS scores.
      One hundred seventy-two (49%) patients were referred to hand therapy. A significantly larger proportion of patients with traumatic injuries (68%) were referred to therapy services than those patients with nontraumatic conditions (40%; P < .01). Among nontraumatic diagnoses, patients with trapeziometacarpal arthritis were most frequently referred to therapy (60%). There was no difference in mean baseline PROMIS scores (depression, anxiety, and pain interference) between patients referred and not referred to therapy. Referral rates were similar between those greater and less than the mental health thresholds: PROMIS depression (49% high scores versus 49% below threshold); PROMIS anxiety (48% high scores vs 49% below threshold); PROMIS pain interference (49% high scores vs 49% below threshold). Logistic regression models showed no significant associations between each of the mental health and pain levels and the incidence of referral to therapy (referred/not referred), although traumatic conditions were three times more likely to be referred to therapy than nontraumatic conditions (Table 2).
      Table 2Multivariable logistic regression association between depression, anxiety, or pain and referral to therapy in separate (n = 308) models
      VariablesModel 1Model 2Model 3
      ORLL CIUL CIORLL CIUL CIORLL CIUL CI
      Depression (above 59.7 vs below)1.000.591.62
      Anxiety (above 62.3 vs below)0.910.501.85
      Pain interference (above 60 vs below)1.070.661.73
      Age (55 y or older vs <55 y)1.070.661.721.070.661.721.060.661.71
      Race (African American vs other)0.580.261.280.580.261.300.580.261.28
      Area deprivation index (50 or higher)0.980.462.190.970.581.620.990.591.65
      Female (vs male)1.100.691.781.110.691.791.100.681.77
      Traumatic condition (vs nontraumatic)3.452.075.813.482.085.833.452.065.77
      LL CI = lower 95th percentile confidence; UL CI = upper 95th percentile confidence limit.
      Missing data: area deprivation index = 42; race = 2.
      Among the 96 patients who were seen by a hand therapist at the orthopedic center, the average number of hand therapy visits was 2.9 (SD 3.4), with a range of 1 to 20 visits. The average number of therapy visits attended by patients with traumatic (3.4 visits) versus nontraumatic injuries (2.5 visits) was not significantly different (P = .23). Patients with high depression scores (above threshold) attended on average one more therapy visit compared with patients with lower depression scores (mean 3.7, SD 5.9 vs mean 2.8, SD 3.1 visits, P = .42). Similarly, patients with high anxiety and high pain scores required on average one more therapy visit compared with those with low scores to achieve goal attainment (anxiety: mean 4.1, SD 5.0 visits versus mean 2.7, SD 3.1 visits, P = .14; pain: mean 3.4, SD 4.2 visits versus mean 2.3, SD 2.2 visits, P = .12), although the difference was not statistically significant. Forty-nine percent of patients received only one therapy visit. A greater proportion of patients with high anxiety received three or more therapy visits than those with low anxiety, and a slightly higher proportion of patients had high pain interference levels than those with low pain levels (Table 3). Only 50% of patients with high PROMIS depression scores met their long-term goals compared with 69% among those with low depression scores (P = .20). There was no difference in short- or long-term goal attainment among patients with high and low anxiety (P = .80 and .84, respectively) and pain scores (P = .90 and .66, respectively). More patients achieved their goals if they had traumatic conditions (70%) compared with nontraumatic conditions (64%) although the comparisons were not significant (short-term goals P = .52; long-term goals P = .39).
      Table 3Three or more therapy visits and therapy goals met among patients with high versus low PROMIS scores and the type of condition (n = 96)
      VariablesDepression scoreAnxiety scorePain interference scoreType of condition
      HighLowPHighLowPHighLowPTraumaticNontraumaticP
      n (%)n (%)n (%)n (%)n (%)n (%)n (%)n (%)
      Three or more therapy visits3 (30.0)28 (32.6).877 (50.0)24 (29.3).1319 (37.3)12 (26.7).2714 (35.0)17 (30.4).63
      Short-term goals met7 (70.0)64 (74.4).7610 (71.4)21 (74.4).8238 (74.5)33 (73.3).9030 (75.0)41 (73.2).84
      Long-term goals met5 (50.0)59 (68.6).249 (64.3)19 (67.1).8433 (64.7)31 (68.9).6628 (70.0)36 (64.3).56
      PROMIS = Patient-Reported Outcomes Measurement Information System; High score = met or exceeded threshold; low score = below threshold; threshold scores: PROMIS depression = 59.9; PROMIS anxiety = 62.3; PROMIS pain interference = 60 (1 SD above the mean).

      Discussion

      Our data indicate that patients with common hand injuries and conditions were not referred to outpatient hand therapy differentially based on higher versus lower levels of depression, anxiety, or pain interference. There was no association between age, sex, or race and mental health or pain status to physician referral to therapy. However, patients with traumatic conditions were referred to therapy over three times as often as those with nontraumatic conditions, regardless of mental health and pain level. Although there was no significant difference in the number of therapy visits based on high versus low depression scores, fewer patients met their long-term goals if they had high depression scores (compared with low depression). Our findings indicate that the determining factor for therapy referral is the severity of injury (presence of trauma and/or need for surgery) rather than the level of mental health or pain. Yet, our finding that higher depression negatively influences goal attainment implies that patients with mental health conditions may need more support throughout their orthopedic recovery.
      The patients in this study had common hand conditions and were treated in an outpatient setting. Their PROMIS data scores are similar to the PROMIS data scores found in previous studies of patients seen for upper extremity orthopedic care.
      • Calfee R.
      • Chu J.
      • Sorensen A.
      • Martens E.
      • Elfar J.
      What is the impact of comorbidities on self-rated hand function in patients with symptomatic trapeziometacarpal arthritis?.
      ,
      • Roh Y.H.
      • Lee B.K.
      • Noh J.H.
      • Oh J.H.
      • Gong H.S.
      • Baek G.H.
      Effect of anxiety and catastrophic pain ideation on early recovery after surgery for distal radius fractures.
      • Patterson B.M.
      • Orvets N.D.
      • Aleem A.W.
      • et al.
      Correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) scores with legacy patient-reported outcome scores in patients undergoing rotator cuff repair.
      There were similar rates of patients who met high clinical threshold values for depression compared with previous reports.
      • Stiegel K.R.
      • Lash J.G.
      • Peace A.J.
      • Coleman M.M.
      • Harrington M.A.
      • Cahill C.W.
      Early experience and results using PROMIS scores in primary total hip and knee arthroplasty.
      Overall, these results confirm high rates of anxiety, depression, and pain interference among patients with orthopedic conditions of the hand, wrist, and shoulder.
      Previous studies have noted a higher rate of patients seeking medical services among those with comorbid mental health conditions.
      • Rosemann T.
      • Joos S.
      • Szecsenyi J.
      • Laux G.
      • Wensing M.
      Health service utilization patterns of primary care patients with osteoarthritis.
      Patients with elevated mental health symptoms attend a higher number of physician visits,
      • Crijns T.J.
      • Bernstein D.N.
      • Teunis T.
      • et al.
      The association between symptoms of depression and office visits in patients with nontraumatic upper-extremity illness.
      as depression is a predictor of chronic health conditions.
      • Rosemann T.
      • Backenstrass M.
      • Joest K.
      • Rosemann A.
      • Szecsenyi J.
      • Laux G.
      Predictors of depression in a sample of 1,021 primary care patients with osteoarthritis.
      In addition, recent literature has emphasized the negative impact of depression on the functional outcome. In a sample of 697 patients with upper extremity peripheral nerve injuries, depression was the primary predictor of high disability ratings.
      • Stonner M.M.
      • Mackinnon S.
      • Kaskutas V.
      Predictors of disability and quality of life with an upper-extremity peripheral nerve disorder.
      Previous authors have also confirmed the strong correlation between depression and outcome scores among the orthopedic hand population.
      • Novak C.B.
      • Anastakis D.J.
      • Beaton D.E.
      • Mackinnon S.E.
      • Katz J.
      Biomedical and psychosocial factors associated with disability after peripheral nerve injury.
      • Cheng H.
      • Novak C.B.
      • Veillette C.
      • von Schroeder H.P.
      Influence of psychological factors on patient-reported upper extremity disability.
      These findings are in keeping with the results of our present study, highlighting that depression is negatively associated with outcomes such as goal attainment.
      Previous studies have not explored referral rates to hand therapy services. Our study shows that hand surgeons are more likely to refer patients to hand therapy based on surgical status or injury type than for symptoms of depression, anxiety, and pain. Patients with higher levels of depression, anxiety, and pain generally received at least one more hand therapy visit, suggesting that these patients require more support to achieve their treatment goals. Although physicians may not use mental health measures to determine the need for therapy services, therapists can use them to optimize patients' clinical course. They can monitor mental health and pain using PROMIS measures to not only guide their language and use of empathy with individuals at greater risk for poorer clinical outcomes but also anticipate the need for greater frequency and/or duration of therapy attendance to achieve maximal functional recovery.
      Our findings highlight the clinical value in addressing symptoms of mental health and pain in a hand therapy setting. Anxiety symptoms may stem from pain, fear of surgery, inability to perform essential occupations, and/or from a lack of realistic expectations regarding functional outcomes.
      • Cheng H.
      • Novak C.B.
      • Veillette C.
      • von Schroeder H.P.
      Influence of psychological factors on patient-reported upper extremity disability.
      ,
      • Sommer M.
      • de Rijke J.M.
      • van Kleef M.
      • et al.
      Predictors of acute postoperative pain after elective surgery.
      • Keogh E.
      • Book K.
      • Thomas J.
      • Giddins G.
      • Eccleston C.
      Predicting pain and disability in patients with hand fractures: comparing pain anxiety, anxiety sensitivity and pain catastrophizing.
      Therapists can use anxiety-reducing techniques to promote empathetic care, educate patients on functional expectations, and prepare patients for stressful experiences. The PROMIS measures may be used to assess mental health and functional status periodically during the rehabilitation process and to provide insight into factors affecting patient outcome. Therapists can also address mental health factors by targeting occupations known to be associated with psychological health, such as work, sleep, and social engagement.
      • Stonner M.M.
      • Mackinnon S.
      • Kaskutas V.
      Predictors of disability and quality of life with an upper-extremity peripheral nerve disorder.
      ,
      • Glass T.A.
      • De Leon C.F.M.
      • Bassuk S.S.
      • Berkman L.F.
      Social engagement and depressive symptoms in late life: longitudinal findings.
      ,
      • Alvaro P.K.
      • Roberts R.M.
      • Harris J.K.
      A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression.
      Orthopedic hand injuries may influence one's self-image, particularly among trauma patients. Patients may guard or hide their injured extremity, and some refuse to visualize, touch, or use the arm.
      • Lewis J.S.
      • Kersten P.
      • McCabe C.S.
      • McPherson K.M.
      • Blake D.R.
      Body perception disturbance: a contribution to pain in complex regional pain syndrome (CRPS).
      An altered body image can negatively affect occupational engagement
      • Rubio K.B.
      • Van Deusen J.
      Relation of perceptual and body image dysfunction to activities of daily living of persons after stroke.
      ,
      • Grob M.
      • Papadopulos N.
      • Zimmermann A.
      • Biemer E.
      • Kovacs L.
      The psychological impact of severe hand injury.
      and contribute to psychological stress. Therapists play an important role in addressing such mental health concerns, preventing dissociation between the patient and the affected extremity, and improving occupational engagement at home and in the community.
      Because pain is both a physical and psychological experience, it is important to address early and often throughout the clinical course to prevent maladaptive pain responses.
      • Lewis J.S.
      • Coales K.
      • Hall J.
      • McCabe C.S.
      ‘Now you see it, now you do not’: sensory–motor re-education in complex regional pain syndrome.
      Throughout the recovery process, therapists can counsel patients about pain perception, promoting healthy responses to pain and teaching strategies to self-manage acute and chronic pain. Previous literature has established the efficacy of pain education through therapy programs such as motor imagery, mirror visualization,
      • Karmarkar A.
      • Lieberman I.
      Mirror box therapy for complex regional pain syndrome.
      breathing techniques, and desensitization. Such rehabilitation strategies have been shown to reduce pain and stiffness,
      • Bowering K.J.
      • O'Connell N.E.
      • Tabor A.
      • et al.
      The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis.
      improve functional hand use,
      • Daly A.E.
      • Bialocerkowski A.E.
      Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review.
      decrease psychological stress, and increase self-efficacy.
      • Feinberg S.D.
      • Feinberg R.M.
      • Page D.
      Functional restoration and complex regional pain syndrome.
      Hand therapists are well positioned to address nonpharmacological pain management as an occupation and as a means to engage in meaningful activities. Therapists can help mediate expectations, educate patients about the recovery process, and promote occupational engagement. The PROMIS pain interference module is useful for therapists in particular, as it evaluates the degree to which pain limits engagement in everyday activities. This tool can be used to not only assess baseline function but also to guide patient-centered interventions and set realistic goals.

      Limitations

      The study data were drawn from regularly collected data in electronic health records, so the initial data draw did not include those patients with missing data or who did not meet study criteria, and potential sample selection bias is not known. PROMIS data are self-reported, which is subject to potential reporting bias. We were also limited in our access to information on past mental health diagnoses and treatment through medication and the ability to measure the effects that these may have had on PROMIS scores. Finally, our sample is drawn from a single orthopedic surgery practice with one corresponding hand therapy clinic, so the results may have limited generalizability.

      Conclusions

      Although surgeons do not currently use mental health or pain factors to determine referral to hand therapy, patients with high levels of pain, anxiety, or depression symptoms attended one more therapy session to achieve their functional goals. In addition, fewer patients achieve their therapy goals if they demonstrate high levels of depression. These patients require more support services to achieve satisfactory outcomes. It is not known if patients with depressive symptoms but not referred to therapy achieve functional recovery. Therapists can use PROMIS measures to monitor these psychosocial and pain factors throughout their clinical course to optimize functional recovery.

      Acknowledgments

      Research reported in this publication was supported by the Washington University Institute of Clinical and Translational Sciences grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH. The authors would like to thank Skye Buckner-Petty, Anna M. Kinghorn, and Dr Bradley Evanoff in the Washington University School of Medicine in St. Louis Occupational Safety and Health Research Lab for their contributions.

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