Full-Length Paper| Volume 35, ISSUE 1, P24-31, January 2022

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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:


      • 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.



      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.


      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.


      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).


      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.


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        • London D.A.
        • Stepan J.G.
        • Boyer M.I.
        • Calfee R.P.
        The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions.
        J Bone Joint Surg Am. 2014; 96: 806-814
        • Beleckas C.M.
        • Prather H.
        • Guattery J.
        • Wright M.
        • Kelly M.
        • Calfee R.P.
        Anxiety in the orthopedic patient: using PROMIS to assess mental health.
        Qual Life Res. 2018; 27: 2275-2282
        • Goebel S.
        • Steinert A.
        • Vierheilig C.
        • Faller H.
        Correlation between depressive symptoms and perioperative pain: a prospective cohort study of patients undergoing orthopedic surgeries.
        Clin J Pain. 2013; 29: 392-399
        • 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?.
        Clin Orthop Relat Res. 2015; 473: 3477-3483
        • 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.
        J Hand Surg Am. 2014; 39: 2258-2264.e2252
        • Beleckas C.M.
        • Padovano A.
        • Guattery J.
        • Chamberlain A.M.
        • Keener J.D.
        • Calfee R.P.
        Performance of patient-reported outcomes measurement information system (PROMIS) upper extremity (UE) versus physical function (PF) computer adaptive tests (CATs) in upper extremity clinics.
        J Hand Surg Am. 2017; 42: 867-874
        • Raichle K.A.
        • Osborne T.L.
        • Jensen M.P.
        • Ehde D.M.
        • Smith D.G.
        • Robinson L.R.
        Preoperative state anxiety, acute postoperative pain, and analgesic use in persons undergoing lower limb amputation.
        Clin J Pain. 2015; 31: 699-706
        • Theunissen M.
        • Peters M.L.
        • Bruce J.
        • Gramke H.F.
        • Marcus M.A.
        Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain.
        Clin J Pain. 2012; 28: 819-841
        • Yeoh J.C.
        • Pike J.M.
        • Slobogean G.P.
        • OʼBrien P.J.
        • Broekhuyse H.M.
        • Lefaivre K.A.
        Role of depression in outcomes of low-energy distal radius fractures in patients older than 55 years.
        J Orthop Trauma. 2016; 30: 228-233
        • Vranceanu A.M.
        • Bachoura A.
        • Weening A.
        • Vrahas M.
        • Smith R.M.
        • Ring D.
        Psychological factors predict disability and pain intensity after skeletal trauma.
        J Bone Joint Surg Am. 2014; 96: e20
        • Pelletier R.
        • Bourbonnais D.
        • Higgins J.
        • Mireault M.
        • Harris P.G.
        • Danino M.A.
        Pain interference may be an important link between pain severity, impairment, and self-reported disability in participants with wrist/hand pain.
        J Hand Ther. 2019; 2020: 13
        • MacDermid J.C.
        • Valdes K.
        • Szekeres M.
        • Naughton N.
        • Algar L.
        The assessment of psychological factors on upper extremity disability: a scoping review.
        J Hand Ther. 2018; 31: 511-523
        • Karsten J.
        • Penninx B.W.
        • Verboom C.E.
        • Nolen W.A.
        • Hartman C.A.
        Course and risk factors of functional impairment in subthreshold depression and anxiety.
        Depress Anxiety. 2013; 30: 386-394
        • Rodríguez M.R.
        • Nuevo R.
        • Chatterji S.
        • Ayuso-Mateos J.L.
        Definitions and factors associated with subthreshold depressive conditions: a systematic review.
        BMC Psychiatry. 2012; 12: 181
        • Karayannis N.V.
        • Sturgeon J.A.
        • Chih-Kao M.
        • Cooley C.
        • Mackey S.C.
        Pain interference and physical function demonstrate poor longitudinal association in people living with pain: a PROMIS investigation.
        Pain. 2017; 158: 1063-1068
        • Cook K.F.
        • Schalet B.D.
        • Kallen M.A.
        • Rutsohn J.P.
        • Cella D.
        Establishing a common metric for self-reported pain: linking BPI pain interference and SF-36 bodily pain subscale scores to the PROMIS pain interference metric.
        Qual Life Res. 2015; 24: 2305-2318
        • Schalet B.D.
        • Cook K.F.
        • Choi S.W.
        • Cella D.
        Establishing a common metric for self-reported anxiety: linking the MASQ, PANAS, and GAD-7 to PROMIS Anxiety.
        J Anxiety Disord. 2014; 28: 88-96
        • Schalet B.D.
        • Revicki D.A.
        • Cook K.F.
        • Krishnan E.
        • Fries J.F.
        • Cella D.
        Establishing a common metric for physical function: linking the HAQ-DI and SF-36 PF subscale to PROMIS(®) physical function.
        J Gen Intern Med. 2015; 30: 1517-1523
        • Braun Y.
        • Mellema J.J.
        • Peters R.M.
        • Curley S.
        • Burchill G.
        • Ring D.
        The relationship between therapist-rated function and patient-reported outcome measures.
        J Hand Ther. 2017; 30: 516-521
        • Döring A.C.
        • Nota S.P.
        • Hageman M.G.
        • Ring D.C.
        Measurement of upper extremity disability using the patient-reported outcomes measurement information system.
        J Hand Surg Am. 2014; 39: 1160-1165
        • Overbeek C.L.
        • Nota S.P.
        • Jayakumar P.
        • Hageman M.G.
        • Ring D.
        The PROMIS physical function correlates with the QuickDASH in patients with upper extremity illness.
        Clin Orthop Relat Res. 2015; 473: 311-317
        • Ring D.
        • Kadzielski J.
        • Fabian L.
        • Zurakowski D.
        • Malhotra L.R.
        • Jupiter J.B.
        Self-reported upper extremity health status correlates with depression.
        J Bone Joint Surg Am. 2006; 88: 1983-1988
        • Cook K.F.
        • Kallen M.A.
        • Bombardier C.
        • et al.
        Do measures of depressive symptoms function differently in people with spinal cord injury versus primary care patients: the CES-D, PHQ-9, and PROMIS(®)-D.
        Qual Life Res. 2017; 26: 139-148
        • Kim J.
        • Chung H.
        • Askew R.L.
        • et al.
        Translating CESD-20 and PHQ-9 scores to PROMIS depression.
        Assessment. 2017; 24: 300-307
        • Menendez M.E.
        • Bot A.G.
        • Hageman M.G.
        • Neuhaus V.
        • Mudgal C.S.
        • Ring D.
        Computerized adaptive testing of psychological factors: relation to upper-extremity disability.
        J Bone Joint Surg Am. 2013; 95: e149
        • Karayannis N.V.
        • Sturgeon J.A.
        • Chih-Kao M.
        • Cooley C.
        • Mackey S.C.
        Pain interference and physical function demonstrate poor longitudinal association in people living with pain: a PROMIS investigation.
        Pain. 2017; 158: 1063-1068
        • Beckmann J.T.
        • Hung M.
        • Voss M.W.
        • Crum A.B.
        • Bounsanga J.
        • Tyser A.R.
        Evaluation of the patient-reported outcomes measurement information system upper extremity computer adaptive test.
        J Hand Surg Am. 2016; 41: 739-744.e734
        • Tyser A.R.
        • Beckmann J.
        • Franklin J.D.
        • et al.
        Evaluation of the PROMIS physical function computer adaptive test in the upper extremity.
        J Hand Surg Am. 2014; 39: 2047-2051.e2044
        • Griffin K.H.
        • Nate K.C.
        • Rivard R.L.
        • Christianson J.B.
        • Dusek J.A.
        Referrals to integrative medicine in a tertiary hospital: findings from electronic health record data and qualitative interviews.
        BMJ Open. 2016; 6: e012006
      1. 2000 area deprivation index.
        (Available at:)
        Date: 2014
        Date accessed: April 24, 2020
        • 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.
        J Biomed Inform. 2009; 42: 377-381
        • Cella D.
        • Riley W.
        • Stone A.
        • et al.
        The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008.
        J Clin Epidemiol. 2010; 63: 1179-1194
        • Schalet B.D.
        • Pilkonis P.A.
        • Yu L.
        • et al.
        Clinical validity of PROMIS Depression, Anxiety, and Anger across diverse clinical samples.
        J Clin Epidemiol. 2016; 73: 119-127
        • Cook K.F.
        • Jensen S.E.
        • Schalet B.D.
        • et al.
        PROMIS measures of pain, fatigue, negative affect, physical function, and social function demonstrated clinical validity across a range of chronic conditions.
        J Clin Epidemiol. 2016; 73: 89-102
        • Schalet B.D.
        • Hays R.D.
        • Jensen S.E.
        • Beaumont J.L.
        • Fries J.F.
        • Cella D.
        Validity of PROMIS physical function measured in diverse clinical samples.
        J Clin Epidemiol. 2016; 73: 112-118
        • Askew R.L.
        • Cook K.F.
        • Revicki D.A.
        • Cella D.
        • Amtmann D.
        Clinical validity of PROMIS® pain interference and pain behavior in diverse clinical populations.
        J Clin Epidemiol. 2016; 73: 103
        • Gershon R.C.
        • Rothrock N.
        • Hanrahan R.
        • Bass M.
        • Cella D.
        The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research.
        J Appl Meas. 2010; 11: 304-314
        • Bevans M.
        • Ross A.
        • Cella D.
        Patient-Reported Outcomes Measurement Information System (PROMIS): efficient, standardized tools to measure self-reported health and quality of life.
        Nurs Outlook. 2014; 62: 339-345
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.
        • Lowe B.
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
      2. Appendix table 34: raw score to T-score conversion table (IRT fixed parameter calibration linking) for GAD-7 to PROMIS anxiety.
        (Available at:)
        • Beleckas C.M.
        • Wright M.
        • Prather H.
        • Chamberlain A.
        • Guattery J.
        • Calfee R.P.
        Relative prevalence of anxiety and depression in patients with upper extremity conditions.
        J Hand Surg. 2018; 43 (571.e571-571.e578)
      3. Appendix table 46: raw score to T-score conversion table (IRT fixed parameter calibration linking) for PHQ-9 to PROMIS depression.
        (Available at:)
        • Wright M.A.
        • Adelani M.
        • Dy C.
        • OʼKeefe R.
        • Calfee R.P.
        What is the impact of social deprivation on physical and mental health in orthopaedic patients?.
        Clin Orthop Relat Res. 2019; 477: 1825-1835
        • 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.
        J Shoulder Elbow Surg. 2018; 27: S17-S23
        • 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.
        J Arthroplasty. 2019;
        • Rosemann T.
        • Joos S.
        • Szecsenyi J.
        • Laux G.
        • Wensing M.
        Health service utilization patterns of primary care patients with osteoarthritis.
        BMC Health Serv Res. 2007; 7: 169
        • 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.
        J Hand Surg. 2019;
        • 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.
        Arthritis Care Res. 2007; 57: 415-422
        • Stonner M.M.
        • Mackinnon S.
        • Kaskutas V.
        Predictors of disability and quality of life with an upper-extremity peripheral nerve disorder.
        Am J Occup Ther. 2017; 71 (7101190050p7101190051-7101190050p7101190058)
        • 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.
        J Bone Joint Surg Am. 2011; 93: 929-936
        • Cheng H.
        • Novak C.B.
        • Veillette C.
        • von Schroeder H.P.
        Influence of psychological factors on patient-reported upper extremity disability.
        J Hand Surg. 2019; (1753193419859373)
        • Sommer M.
        • de Rijke J.M.
        • van Kleef M.
        • et al.
        Predictors of acute postoperative pain after elective surgery.
        Clin J Pain. 2010; 26: 87-94
        • 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.
        Eur J Pain. 2010; 14: 446-451
        • Glass T.A.
        • De Leon C.F.M.
        • Bassuk S.S.
        • Berkman L.F.
        Social engagement and depressive symptoms in late life: longitudinal findings.
        J Aging Health. 2006; 18: 604-628
        • Alvaro P.K.
        • Roberts R.M.
        • Harris J.K.
        A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression.
        Sleep. 2013; 36: 1059-1068
        • 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).
        Pain. 2007; 133: 111-119
        • Rubio K.B.
        • Van Deusen J.
        Relation of perceptual and body image dysfunction to activities of daily living of persons after stroke.
        Am J Occup Ther. 1995; 49: 551-559
        • Grob M.
        • Papadopulos N.
        • Zimmermann A.
        • Biemer E.
        • Kovacs L.
        The psychological impact of severe hand injury.
        J Hand Surg. 2008; 33: 358-362
        • 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.
        Hand Ther. 2011; 16: 29-38
        • Karmarkar A.
        • Lieberman I.
        Mirror box therapy for complex regional pain syndrome.
        Anaesthesia. 2006; 61: 412-413
        • 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.
        J Pain. 2013; 14: 3-13
        • Daly A.E.
        • Bialocerkowski A.E.
        Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review.
        Eur J Pain. 2009; 13: 339-353
        • Feinberg S.D.
        • Feinberg R.M.
        • Page D.
        Functional restoration and complex regional pain syndrome.
        Pract Pain Manage. 2008; : 14-20

      JHT Read for Credit

      Quiz: # 809

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • # 1.
        The study design is
        • a.
        • b.
          case series
        • c.
          prospective cohort
        • d.
          retrospective cohort
      • # 2.
        The correlation between therapy utilization and the PROMIS was calculated using
        • a.
          the Kappa correlation coefficient
        • b.
          a 2 way ANOVA
        • c.
          a Pearson correlation coefficient
        • d.
          the Student T Test
      • # 3.
        Raw data were inputted by
        • a.
          patients on an I Pad Mini
        • b.
          therapists on hand-written chart notations
        • c.
          surgeons following patient return to clinic visits
        • d.
          insurance company case workers
      • # 4.
        In a patient population who had sustained traumatic hand injuries approximately __________ percent were referred to hand therapy
        • a.
        • b.
        • c.
        • d.
      • # 5.
        The authors concluded that anxiety and depression seldom provoke referrals to hand therapy
        • a.
          not true
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.