Distal radius fracture: relationships between psychological factors and recovery
Goudie, Stuart Thomas Goudie
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Distal radius fracture is a common injury. The majority of people recover well but a proportion have ongoing pain, stiffness, deformity and functional limitation. Associations between these outcomes, injury characteristics and treatment methods are inconsistent, for example a deformed wrist is not always painful, stiff and functionally limiting. The psychological response to fracture and the role that psychological factors play in recovery are complex and poorly understood. Identification and treatment of those psychological factors that might influence disability and symptom intensity could improve outcomes in this large group of patients. The aim of this thesis is to explore the influence of psychological factors on outcome following fracture of the distal radius. To investigate these relationships further a literature review was carried out looking at the association between psychological factors and outcomes in distal radius fracture patients. Prospective studies were then performed in order to identify associations between demographic factors, injury severity, treatment and psychosocial factors and symptom intensity and disability after fracture and to identify predictors of psychological response to injury. A prospective randomised controlled trail (RCT) was then carried out to compare the impact of an additional psychological workbook intervention versus an information workbook in the otherwise routine management of distal radius fracture. The literature review identified evidence to support the association between psychological factors and outcome after acute injury in general but limited evidence specifically pertaining to distal radius fracture. The first prospective study of 216 patients found psychosocial factors to be more strongly associated with disability (Disability of Arm Shoulder and Hand score, DASH) and pain intensity after distal radius fracture than any injury or treatment factor. The second prospective study of 153 patients found that psychological traits are relatively stable in this cohort and that no demographic, injury or treatment factors were associated with the small changes in psychological scores up to 10 weeks following injury. The RCT demonstrated that use of a psychological workbook did not significantly improve disability six weeks after injury compared to an information workbook in a cohort of patients with distal radius fracture (DASH 38 vs 35, p = 0.949). The importance of psychosocial factors in recovery from distal radius fracture has been demonstrated. Following this injury, psychological factors remain stable over time or fluctuate to a small degree with distinct trends. In cohorts with stable psychological responses to fracture, the individual psychological response cannot be reliably predicted by demographic, injury or treatment factors. Use of a psychological workbook intervention does not improve outcomes in patients with a good initial psychological response to injury. Future work should investigate less psychologically stable and well adapted cohorts, establish how best to identify patients at risk of poor outcome and whether, indeed, these specific groups are amenable to treatment and if so what form this intervention should take. It should address limitations identified in this work, primarily, reduce questionnaire fatigue with more focused psychological questionnaires. Ultimately, it should work towards creating a structure where patients can be screened with a recognised psychological scoring system at initial presentation to fracture clinic and allow a sub-group of psychologically mal-adpted patients to be referred on to a dedicated psychology service, that would work to optimise the psychological conditions for recovery.