Severity of Persistent Pain and Associated Psychological Factors in Distal Radius Fractures

Authors and Affiliations

  • Mohammad Mahdavi
    a Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

  • Maryam Farzad
    b School of Physical Therapy, Department of Health and Rehabilitation Sciences, University of Western Ontario, London, Ontario, Canada
    c University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

  • Saurabh P. Mehta
    d School of Physical Therapy, Marshall University, Huntington, WV, USA
    e Department of Orthopedic Surgery, Joan C Edwards School of Medicine, Marshall University, Huntington, WV, USA

  • Joy C. MacDermid
    f Physical Therapy and Surgery, Western University, London, ON, Canada
    g Co-director Clinical Research Lab, Hand and Upper Limb Center, St. Joseph’s Health Center, London, Ontario, Canada
    h Professor Rehabilitation Science McMaster University, Hamilton, ON, Canada

  • Mohsen Vahedi
    i Department of Biostatistics and Epidemiology, University of Social Welfare and Rehabilitation Science, Tehran, Iran

  • Seyed Ali Hosseini
    a University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

  • Erfan Shafiee
    b School of Physical Therapy, Department of Health and Rehabilitation Sciences, University of Western Ontario, London, Ontario, Canada

  • Amir Reza Farhoud
    j Imam Hospital Complex, Tehran University of Medical Sciences, Joint Reconstruction Research Center, Iran

Keywords

  • Distal radius fracture

  • Pain

  • Disability

  • Pain catastrophizing

  • Psychological factors

Abstract

Background

  • Evidence indicates that psychological factors are relevant for individuals with persistent residual pain and disability over the longer term after distal radius fractures (DRF), however, further inquiry is required.

Objectives

  • Examine associations of persistent wrist pain and disability after DRF with psychological factors at 6-months post-fracture.

Methods

  • 85 patients with DRF were evaluated using the Patient-rated wrist evaluation (PRWE) for pain and disability at 6-months post-fracture.

  • Multivariable logistic regression models were used to examine associations between wrist pain/disability and psychological factors.

  • The ability of PRWE scores to classify individuals with and without psychological factors was assessed using the area under the receiver operating characteristic curve (AUC).

Results

  • Higher PRWE pain (PRWE-P) and function (PRWE-F) scores were significantly associated with worse pain catastrophizing, emotional distress, and fear of wrist movements.

  • PRWE-P or PRWE-F scores of ≥18/50 showed the best sensitivity and specificity for identifying psychological factors (AUC values ≥0.88).

Conclusion

  • Scores of ≥18/50 on PRWE-P or PRWE-F can be used to screen for psychological factors in patients after DRF.

1. Background

  • DRF is among the most common hand and upper extremity fractures, with a notable percentage of patients reporting chronic pain and functional limitations even after 6-months post-injury.

  • The healing process typically plateaus at this stage, indicating a need for intervention and further evaluation of pain and functional capacity.

Persistent Pain Factors

  • Factors associated with ongoing pain and functional limitations post-DRF may include:

    • Injury-related variables

    • Concurrent wrist/hand injuries

    • Reported pain levels shortly after injury

    • Presence of psychological factors, such as:

    • Depression

    • Pain catastrophizing

    • Fear of movement

2. Methods

2.1 Study Design and Participants

  • Cross-sectional study approved by the institutional review board.

  • 85 participants recruited between February 2019 – February 2020 from hand surgery clinics.

    • Inclusion criteria:

    • Surgical management for DRF

    • Age ≥ 18 years

    • Informed consent

    • Exclusion criteria:

    • Major medical comorbidities

    • Behavioral condition management

    • Cognitive impairments

  • Demographics recorded: age, gender, job, hand dominance, education, and type of orthopedic management.

2.2 Outcome Measures
2.2.1 Patient-rated Wrist Evaluation (PRWE)

  • Measures wrist pain and function using subscales:

    • PRWE-P (pain subscale): 5-items assessing frequency and intensity of pain.

    • PRWE-F (function subscale): 10-items evaluating functional limitations.

  • Scores range: 0 (no pain/difficulty) to 100 (extreme pain/difficulty).

2.2.2 Pain Catastrophizing Scale (PCS)

  • 13-item measure assessing pain catastrophizing via rumination, magnification, and helplessness.

  • Score range: 0 to 52, with higher scores indicating greater catastrophizing.

  • A score of ≥16 is considered indicative of chronic pain-related issues.

2.2.3 Depression, Anxiety, and Stress Scale (DASS-21)

  • 21-item scale measuring adverse psychological symptoms over the past week.

  • Scores range from 0 to 63, with ≥34 indicating significant distress.

2.2.4 Tampa Scale for Kinesiophobia (TSK)

  • 17-item questionnaire measuring fear of movement, with a score range from 0 to 68.

  • A score of ≥37 indicates fear of movement related to the affected wrist/hand.

2.3 Statistical Analysis

  • Sample characteristics summarized using means and SDs for continuous variables and frequencies for categorical variables.

  • Logistic regression models used for pain catastrophizing, emotional distress, and fear of movement as dependent variables.

  • AUC determined the discrimination ability of PRWE scores with specific attention to sensitivity and specificity measures.

  • Statistical significance set at p < 0.05.

3. Results

Sample Characteristics

  • Participants: 85 individuals (58 men, mean age 45.15 years)

  • Pain and disability scores ranged as follows:

    • TSK: 23 - 61

    • PCS: 0 - 52

    • DASS-21: 0 - 45

    • PRWE Total: 0 - 85

  • Findings demonstrated significant associations between higher PRWE scores and the presence of psychological factors.

Logistic Regression Findings

  • Higher PRWE-P scores were associated with:

    • Pain catastrophizing: OR 1.57, p=0.002

    • Emotional distress: OR 1.25, p=0.03

    • Fear of wrist movements: OR 1.27, p<0.0001

  • Higher PRWE-F scores correlated similarly with psychological outcomes.

Receiver Operating Characteristic (ROC) Curves

  • AUC values consistently exceeded 0.88, indicating excellent predictive ability for psychological factors.

  • Score thresholds of ≥18 on PRWE-P and PRWE-F effectively identified individuals at risk for psychological distress.

4. Discussion

Implications of Results

  • Findings suggest that assessing pain and function at 6-months after DRF can serve as a valid screening tool for psychological factors.

  • Previous literature correlates psychological issues with chronic pain, reinforcing the validity of such screenings.

  • Recommendations for clinical practice include integrating PRWE as a primary screening tool to reduce administrative burdens.

Limitations and Future Research

  • Lack of baseline data limits understanding of causal relationships between psychological factors and chronic pain.

  • Future studies should include psychological assessments sooner post-injury.

5. Conclusion

  • Scores of PRWE-P or PRWE-F ≥18 at 6 months post-DRF are efficient indicators for screening psychological factors such as pain catastrophizing, emotional distress, and fear of movement, offering significant potential for improving clinical decision-making in rehabilitation.

References

  • Detailed reference list included from previous sections, providing foundational support for presented data and claims.