PSYCHOLOGICAL PROFILE OF PATIENTS WITH DISTAL

RADIUS FRACTURE:
Introduction:
Distal radius fracture has been found to be most common type of fracture in UE
and it represents 17.5% of all types of fractures and have been found to be
greater in women and it is greater in old age without any
predisposition (1,2)Complete articular fracture being one of the most common
fracture patterns and 2R3A2 is the most frequent type (1). The main causative
factors are low energy trauma within the home environment, a fracture post
sports trauma. Rate of recovery after distal radius fracture varies from patient to
patient. Recovery from distal radius fracture is influenced by series of
demographic and psychosocial variables (3).

Psychological factors have found to be predictive of surgical outcomes and play

an important role in the patient’s recovery, even with the presence of clinical
factors (4).Psychological factors accounts for a greater variability as seen among
individuals with disability associated with differential levels of impairment, and
ineffective coping strategies which lead to prolonged symptoms and
disability (4). The World Health Organization (WHO) acknowledges the effect
of psychological factor in conversion of pathological processes to disability (5).

Pain catastrophizing and fear of performing movements is a normal protective

mechanism to initial pain which limits the joint movements and thereby
preventing further tissue damage, but if it remains for a prolonged duration, it
can affect the patient’s outcome and performance (4). Catastrophic thinking can
be defined as excessive negative thinking regarding a painful stimulus which
causes an individual to have anxiety and excessive avoidance behavior and
leads to chronic pain.

Early identification of modifiable psychological factors can be assessed using

patient outcome measures which can speed-up one’s recovery (5). Psychological
treatments are aimed at decreasing pain and increasing upper extremity physical
function and targets both pain catastrophizing and psychological inflexibility (6).
Hesitation of movement initiation is intertwined with subjective factors such as
pain at rest, pain during movement (7). Movement hesitation are major clinical
hallmarks indicating the possible progression of acute pain into chronic pain (7).
 Outcome measures such as Pain Catastrophizing Scale (PCS)( (2) ; (4)and
Tampa Scale of Kinesiophobia will be used to determine the presence of
psychological factors (2). The aim of the study is to explore the psychological
factors such as pain catastrophizing and fear of performing movements at the
baseline in patients with DRF.
LITERATURE REVIEW:

PUBLISHING STUDY METHODOLOGY RESULTS LIMITATIONS

YEAR

1.2022 Severity of persistent AIM: It was found that Uncertainty that

pain and disability can To find association of PREW-P\F score behavioural
accurately screen for persistent wrist pain were impairments,
pain catastrophizing and and disability at 6 independent psychological
fear of performing wrist months after drf w.r.t predictors of pain factors were prior
movements in individuals psychological factors. catastrophizing, to the injury which
with drf. (2) emotional lead to chronic
distress and fear wrist pain.
Mohammad Mahdavi,
METHODOLOGY: of performing
Eighty-five patients with
Maryam Farzad, Saurabh movements.
DRF were evaluated for
P Mehta, Joy C.
wrist pain and disability
MacDermid, Mohsen
with subscales of
Vahedi, Seyed Ali
Patientrated wrist
Hosseini, Erfan Shafiee,
evaluation (PRWE), 6-
Amir Reza Farhoud.
months after the
fracture.

STUDY DESIGN:
Cross Sectional

OUTCOME MX:
Patient Rated Wrist
Evaluation
(PRWE) –at 6 months
Pain Catastrophizing
Scale(PCS): at 6 months

DASS-21 (Depression
anxiety and stress scale)
– at 6 months

Tampa scale of
kinesiophobia -
At 6 months
2. 2014 Effect of Anxiety and Pain AIM: There was an The usage of
Ideation on Early Evaluating preoperative increase in the continuous scores
recovery after surgery for anxiety and pain PCS score w.r.t for pain anxiety
distal radius fractures(4) catastrophizing on the wrist ROM and catastrophic
recovery after drf. and grip strength pain ideation
Roh Young Hak , Lee only at week 4. could have limited
Beom Koo, Noh Jung Ho , An increase in the the patient
Oh Joo Han , Gong Hyun
METHODOLOGY: PASS score was selection.
Subjects: 143
Shik , Baek Goo Hyun. associated with
AGE: 20 years and older
the wrist ROM at the patients were
with a DRF treated by
week 4 and grip limited to one
volar plate fixation.
strength at weeks ethnic population
4 and 12. drawn from an
Pain Catastrophizing
According to a urban area, and
Scale (PCS) and the Pain
multivariate cannot be
Anxiety Symptom Scale
regression generalized as a
(PASS).
analysis, an whole.
increase in the
TIMELINE: at 4-, 12-, PCS score was
and 24-weeks’ post- associated with a
surgery. decrease in grip
strength, ROM,
STUDY TYPE: and MHQ score
prospective cohort at week 4; an
study increase in the
PASS score was
associated with a
decrease in grip
strength, ROM,
and MHQ score
at week 4 and
grip strength and
MHQ score at
week 12. At week
24, only age and
fracture severity
were associated
with the MHQ
score.
3. Baseline Pain Intensity Is AIM: A score of greater The study was still
a Predictor of Chronic Evaluating whether than or equal to unable to explain
Pain in Individuals with baseline pain intensity 12.5/50 at 1-year a substantial
Distal Radius Fracture(8) is a predictor of chronic follow-up for the amount of
pain and wrist/hand pain subscale and variance in chronic
Saurabh.P. Mehta Joy.C. functions at 1 year the function pain at 1 year.
MacDermid Julie following distal radius subscale of the Then , the
Richardson, Norma.J. fracture (DRF) PRWE was condition index
Macintyre, Ruby Grewal defined as was 24, which
chronic pain and suggests the
METHODOLOGY: MSKD, possibility of
Subjects were to be of
respectively. multicollinearity
18 years of age, and
had to have a DRF
within past 2 weeks

OUTCOME MX:
Patient Rated Wrist
Evaluation
(PRWE)

TIMELINE: 1 to 2
days of initial
appointment, as well as
at 8 weeks, 3 months, 6
months, 1 year, and 2
years after the date of
injury.

STUDY TYPE:
retrospective analysis

4. 2022 The Association Between AIM: RESULTS: The psychological

Psychological Factors and To Identify Higher 9-month questionnaires
Outcomes After Distal psychological factors DASH scores used were large in
Radius Fracture(5) associated with pain were associated number and often
intensity and disability with increased in length; this can
following DRF, age, increased create
Stuart T. Goudie, Ryan deprivation questionnaire
Broll, Catherine Warwick, scores, increased fatigue.
Diane Dixon David Ring,
METHODOLOGY: numbers of
219 subjects had to
Margaret McQueen medical
have a DRF within the
comorbidities,
past 4 weeks.
A greater degree
AGE: All skeletally of radial
mature patients age 16 shortening,
and over were included, increased HADS
regardless of treatment Depression
type. subscale scores,
and lower RLOC
 STUDY TYPE: scores.
Prospective Cohort
A higher 10-week
pain score was
TIMELINE AND associated with
OUTCOME MX: increased
Hospital Anxiety and deprivation and
Depression Score IPQB scores.
[HADS], Pain
Catastrophizing Scale, A higher pain
Posttraumatic Stress score at 9 months
Disorder Checklist- was associated
Civilian, Tampa Scale for with an increased
Kinesiophobia , Illness number of
Perception medical
Questionnaire Brief comorbidities.
[IPQB], General Self-
Efficacy Scale, and
Recovery Locus of
Control [RLOC]) were
assessed at 10 weeks
and then again at 9
months .

5.2023 Association between AIM: Scores of pain Most of the

Pain, Catastrophic Finding association intensity and subjects were
Thinking, and Health- between pain and catastrophic employed.
related Quality of Life in catastrophic thinking thinking were
Patients with Hand and the relationship significantly They were unable
Fractures.(9) between catastrophic positively to investigate
thinking and health- correlated, and hand dysfunction
Shinya Oomoto, related quality of life catastrophic as well in this
Mitsuhiro Aoki, and (QOL) in patients with thinking and study.
Toshihiro Honke hand fracture. health related
QOL were
significantly
METHODOLOGY: negatively
The subjects were
correlated.
patients with hand
fractures who were
aged 20 years or older
and received
occupational therapy at
Japan Agricultural
Cooperatives, Obihiro
Kohsei Hospital.

OUTCOME MX
AND TIMELINE:
 Numeric Rating Scale
(NRS), Pain
Catastrophizing Scale,
health related QOL
based on the Short
Form 8 questionnaire
(SF-8
were collected between
4 and 6 months’ post-
treatment.

6.2023 Pain Catastrophizing AIM: RESULTS: Here patients were

Mediates the Effect of
Psychological Inflexibility
on Pain Intensity and
Upper Extremity Physical
Function in Patients with
Upper Extremity Illness(6)
Mojtaba Talaei-Khoei;
Stefan F. Fischerauer, Lee
Sang Gil, MDDavid
RingAna-Maria Vranceanu
In determining They found that limited to upper
the association psychological extremity conditions,
between the inflexibility and results may not
general construct affected pain necessarily generalize
of psychological intensity and to patients with pain
inflexibility and upper extremity complaints in other
pain intensity, and physical function body location.
upper extremity directly and
physical function indirectly.
in patients with Pain
musculoskeletal catastrophizing
illness in a clinical whereas
setup. depression or
anxiety mediated
METHODOLOGY: the association of
108 patients with psychological
upper extremity inflexibility to pain
illness intensity and
upper extremity
STUDY TYPE: physical function
Cross Sectional

OUTCOME MX
AND TIMELINE:
Patient-Reported
Outcomes
Measurement
Information
System.
1.PROMIS Scale
(v1.0) Pain
Intensity 3a
2.PROMIS Bank
(v1.2) Upper
 extremity physical
function CAT
3.PROMIS Bank
(v1.0) Depression
CAT.
4.PROMIS Bank
(v1.0) Anxiety
CAT.
5.Acceptance and
Action
Questionnaire-II.
6.Pain
Catastrophizing
Scale
7. 2019 The mediating effect of AIM: RESULTS: LIMITATIONS:
psychological factors on To investigate how It was found that The sample size was
the relationship between the pain relatively small.
psychological
pain intensity and wrist intensity, as
factor’s, mediate
joint function(10) measured by They were unable to
the relationship patient-rated determine the
between pain wrist evaluation, mechanisms underlying
Yuki Hiraga, Shinya intensity and wrist had significant the relationship
Hisano, Aya Mizunoe & function. indirect effects between wrist function,
Katsuhiro Nomiyama on the hospital pain intensity, and
METHODOLOGY anxiety and psychological factors
: depression scale- because as the study
anxiety and pain did not measure
No of subject’s: 21
self-efficacy neurotransmitter
with DRF
questionnaire. levels.

OUTCOME MX
AND TIMELINE:
The patients were
being evaluated
for pain and
psychological
factors
involvement at
week 1 and week 4
post DRF surgery
using pain self-
efficacy
questionnaire
(PSEQ), hospital
anxiety and
depression scale
(HADS) and Pain
Catastrophizing
Scale(PCS) and
wrist function was
 measured using
Patient Rated Wrist
Evaluation
(PRWE) at week1
and week 12 post
surgery.

NEED OF STUDY:
As stated above DRF is associated with psychological factors such as pain
catastrophizi.ng and fear of performing movement. The previous research
mentions assessing pain catastrophizing and fear of performing movements at
1,4,8,10,12weeks 6 months and 2years post-surgery and none at the baseline or
immediately after the surgery. Although different studies have been conducted
and proven this at different timelines however there’s a need to do the study at
the baseline. Hence there is a need to devise a profile of the patients at the
baseline post distal radius fracture regardless of being conservative or
operatively managed. As the other articles only being assessed few weeks’ post-
surgery.

AIM: To explore the psychological factors such as pain catastrophizing and fear
of performing movements at the baseline in patients with DRF.

PURPOSE: To find the role of pain catastrophizing and fear of performing wrist
movements in patients with wrist pain after distal radius fracture (DRF).

OBJECTIVE:
1. To evaluate pain catastrophizing factors.
2. To evaluate fear of performing movement factor

METHODOLOGY:
MATERIALS AND METHODS:
STUDY DESIGN: descriptive cross-sectional study.
SETTING: Conducted at tertiary care hospital Kasturba Medical College,
Mangalore. OPD, IPD setting.
SUBJECT RECRUITMENT: All subjects with distal radius fracture
INCLUSION CRITERIA: Subjects will be of individuals of both gender
between 18 to 74 years. Patients having distal radius fracture treated with both
operative and conservative management.
EXCLUSION CRITERIA: Subjects will be excluded if they have any other
major fracture (ulnar fracture, humerus fracture etc.), other major tendon
injuries, Autoimmune diseases such as systemic lupus erythematosus, ankylosis
spondylitis, head injury, psychosis, bipolar disorder, chronic pain disorder,
active substances abuse.
SAMPLE SIZE: Sample size will be calculated from the reference article
(Mohammad Mahdavi, Maryam Farzad, Saurabh P Mehta, Joy C. MacDermid,
Mohsen Vahedi, Seyed Ali Hosseini, Erfan Shafiee, Amir Reza Farhoud.)
PROCEDURE: The protocol will be presented to the institution of ethics
committee on approval permission will be taken from the medical superintend
to conduct the study. The study will be performed and reported according to
reporting checklist for cross sectional study based on the (Strengthening the
Reporting Of Observational Studies In Epidemiology) STROBE cross sectional
guidelines.
Patients with distal radius fracture are being evaluated initially after DRF to
examine the correlation between psychological factors such as pain and
demographic data is collected such as name, age, gender, height, weight, BMI is
calculated, which UE is being involved and presence of any other comorbidities
and any joint pain within the UE are noted. Descriptive analysis
PSYCHOLOGICAL MEASURES:
1.Pain Catastrophizing Scale(PCS):
 Pain Catastrophizing Scale (PCS) is a 13-item self-report measure which
assess catastrophic thinking related to pain in individual’s with or without
chronic pain. The scale uses a 5-point Likert scale, from 0 (not at all) to 4
(always), here patients are asked to rate how often they experience the
mentioned thoughts and feelings when they are in pain. It has subscales
which includes rumination, magnification, and helplessness and has a
combined score range of 0-52. Rumination: Items 8,9,10, 11 and
Magnification: Items 6,7,13 and Helplessness: Items 1,2,3,4,5,12. Test
scores more than 15 is associated with poor return to work and more than
 14 is associate with the worst severity in patient with acute pain. For this
we used the score of more than or equal to 16 as the cut off score
indicating worse pain catastrophizing after distal radius fracture (2,4)

2. Tampa Scale of Kinesiophobia (TSK):

It is a psychological measure, which is a 17-item assessment checklist. It
uses a 4-point Likert scale (Strongly Disagree-Disagree-Agree-Strongly
Agree) which are to the model of fear-avoidance, fear of work-related
activities, fear of movement, and fear of re-injury. The scale is divided into 2
parts:
 Activity Avoidance – here the belief that activity may result in (re)injury
or increased pain (TSK-AA)
 Somatic Focus – here individuals believe that pain is a sign of underlying
and serious medical issues (TSK-SF)
The score ranges from 17 to 68. The lowest 17 means no or negligible
kinesiophobia, and the higher the score, the higher the fear of
movement/(re)injury of the patient. If the score is >37, the patient is
considered to suffer from kinesiophobia (2, )

STATISTICAL ANALYSIS:
Descriptive analysis is calculated by using means and standard
deviations using numerical variable such as age and categorical
variable such as gender, dominant side. Mean and Standard Deviation
(SD) scores at the baseline for Pain Catastrophizing Scale and Tampa
Scale of Kinesiophobia will be calculated as well. The data will be
reported based on sex ( female\ male) , age ( 18 to 74), dominant
side(right\left), injured side(right\left),orthopaedic-
management(surgical\conservatively).

IMPLICATIONS:
 1. Generating a psychological profile of an individual with distal radius
fracture helps us in understanding how the psychological factors such as
pain catastrophizing and fear of performing wrist movements affects
one’s rate of recovery and functional outcome eventually.

2. It also helps us in analyzing whether these individuals are prone to having

psychological distress.
3. Furthermore it gives us an insight on how psychological factors
influence pain management as well as prognosis of the rehabilitation
process.

4. Also to know whether these factors would deteriorate or enhance with

time.

REFERENCES :

1.V. Candela, P. Di Lucia, C. Carnevali, et al. Epidemiology of distal radius

fractures: a detailed survey on a large sample of patients in a suburban area ,
Journal of Orthopaedics and Traumatology volume 23, Article number: 43
(2022).
2. Mohammad Mahdavi, Maryam Farzad, Saurabh P Mehta , et al. Severity of
persistent pain and disability can accurately screen for presence of pain
catastrophizing and fear of performing wrist movements in individuals with
distal radius fracture , Musculoskeletal Science and Practice (2022) 57 102474.
3. Prakash Jayakumar , Teunis Teun , Vranceanu Ana Maria, et al . Early
Psychological and Social Factors Explain the Recovery Trajectory After Distal
Radial Fracture , Journal of Bone and Joint Surgery (2020) 102(9) 788-795
4.Young Hak Roh , Beom Koo Lee , Jung Ho Noh , et al. Effect of Anxiety and
Catastrophic Pain Ideation on Early Recovery After Surgery for Distal Radius
Fractures, The Journal of Hand Surgery, (2014), 2258-2264.e2, 39(11)
5. Stuart T Goudie , Ryan Broll , Catherine Warwick, et al. The Association
Between Psychological Factors and Outcomes After Distal Radius Fracture ,
The Journal of Hand Surgery (2022) 47(2) 190.e1-190.e10.
6. Mojtaba Talaei-Khoei , Stefan F Fischerauer, Sang-Gil Lee , et al. Effect of
Psychological Inflexibility on Pain Intensity and Upper Extremity Physical
Function in Patients with Upper Extremity Illness, Pain Practice (2017) 17(1)
129-140.
7. R Imai , M Osumi , et al. Relationship between pain and hesitation during
movement initiation after distal radius fracture surgery: A preliminary study.
8. Saurabh.P. Mehta , Joy.C. MacDermid , Julie Richardson, et al. Baseline Pain
Intensity Is a Predictor of Chronic Pain in Individuals With Distal Radius
Fracture , Journal of Orthopaedic & Sports Physical Therapy (2015) 45(2) 119-
127.
9.Shinya Oomoto, Mitsuhiro Aoki, Toshihiro Honke , Association between
Pain, Catastrophic Thinking, and Health-related Quality of Life in Patients with
Hand Fractures, Progress in rehabilitation medicine (2023) 8 20230016.
10. Yuki Hiraga, Shinya Hisano, Aya Mizunoe , et al . The mediating effect of
psychological factors on the relationship between pain intensity and wrist joint
function , Disability and Rehabilitation (2021) 43(13) 1814-1818.