تغییرات در افسردگی، اضطراب سلامت و فاجعه سازی درد مابین ثبت نام و یک ماه بعد از شکستگی شعاع

Objectives To test the difference in symptoms of (1) depression, (2) health anxiety, and (3) catastrophic thinking between one and six weeks after injury to the radius. Patients and Methods Sixty-nine adult patients with a minimally displaced radial head or distal radius fracture were prospectively enrolled. After diagnosis we recorded demographic variables, 11-point ordinal numerical pain score and agreement with “no pain, no gain,” Disability of the Arms, Shoulder, and Hand (DASH) questionnaire, Center for Epidemiologic Studies Depression (CESD) Scale, the Whiteley Index, and the Pain Catastrophizing Scale (PCS). Fifty-five patients (80%) returned after 1 month to reevaluate pain, DASH, CESD, Whiteley Index, and PCS scores. Results CESD scores decreased by an average of 5±9 points (P<0.001) and Pain Catastrophizing Scale scores decreased by 2±6 points (P=0.0041). In multivariable analysis, decrease in CESD was associated with not having an additional pain condition, more days elapsed between injury and final evaluation, and stronger agreement with “no pain, no gain” (adjusted R2 0.26, P = 0.0006). An increase in Whiteley scores was associated with fewer years of education (R = -0.34; P= 0.012). Changes in PCS scores were associated with marital status (single -1.7±4.3 vs. married -4.6±6.0 vs. separated 0.55±6.2, P=0.040). Conclusions Symptoms of depression and catastrophic thinking, but not health anxiety, improved during recovery after injury. If psychological measures are used as a screening tool to predict outcome after treatment, one should account for a patient’s disease phase. Level of Evidence Prognostic level I

Psychological factors such as symptoms of depression, health anxiety, and catastrophic thinking are associated with increased magnitude of disability and pain intensity in patients with musculoskeletal illness.1 Those constructs can be quantified using validated questionnaires that have good test–retest reliability in stable individuals.2, 3 and 4 However, the performance of these questionnaires during recovery is unknown. Symptoms of depression might be in part reactive and may change over time as patients recover. For example, a previous study showed symptoms of depression decreased one year after hip fracture surgery from 51% to 20%.5 But health anxiety and catastrophic thinking may be more stable constructs, less affected by recovery. This study aims to assess magnitude of change from baseline to 1 month for 3 important constructs associated with pain and disability in orthopedic patients. Specifically, this study tested the primary null-hypothesis that there is no difference in symptoms of (1) depression, (2) health anxiety, and (3) catastrophic thinking between approximately one and six weeks after injury among patients with non-operatively-treated radial head and distal radius fractures. Secondarily, we assessed the association of demographic variables with change in questionnaire scores for depression, health anxiety, and pain catastrophizing.

The average CESD and PCS scores decreased slightly but significantly over time (Table 2). CESD scores decreased by an average of 5±9 points (27±102%, P <0.001) and PCS scores decreased by 2±6 points (9±28%, P = 0.0041). Table 2. Psychological Questionnaires at 1 and 5 weeks after injury Questionnaire 1 week after injury 5 weeks after injury Pvalue Change in questionnaire Percent change Center for Epidemiologic Studies Depression Scale 12±7.7 6.2±7.0 <0.001 -4.7±9.3 -27±102% Whiteley Index 3.2±2.6 2.6±1.9 0.084 -0.56±1.9 -3.4±97% Pain Catastrophizing Scale 18±5.1 15±3.7 0.0041 -2.3±5.7 -9.2±28% Values as mean (±standard deviation); bold indicates statistically significant difference (P < 0.05). Table options In bivariate analysis, increase in symptoms of depression was associated with a preexisting pain condition, less time between injury and final evaluation, and lower “no pain, no gain” agreement. Accounting for potential interaction of variables using multivariable analysis, decrease in CESD was associated with not having an additional pain condition (β-regression coefficient [β] 5.8, partial R2 0.078, 95% confidence interval [CI] 0.616 to 11, P =0.049), more days elapsed between injury and final evaluation (β -0.23, partial R2 0.14, 95%CI -0.39 to -0.067, P =0.007), and stronger agreement with “no pain, no gain” (β -1.2, partial R2 0.14, 95% CI -2.1 to -0.35, P =0.007) (adjusted R2 0.26, P = 0.0006) ( Table 3). In other words, having an additional pain condition increases CESD score on average by 5.8 points; each additional day decreased the CESD score by 0.23 points; and on average, a one-point increase in agreement decreases CESD score by 1.2 points. Table 3. Factors associated with change in questionnaire score Change in questionnaire between 1 and 5 weeks after injury Demographic variables Center for Epidemiologic Studies Depression Scale Pvalue Whiteley Index Pvalue Pain Catastrophizing Scale Pvalue Age (range), years [r] -0.0079 0.96 -0.071 0.61 0.0047 0.97 Sex Male -5.2±8.1 0.82 -0.6±1.8 0.94 -2.1±3.5 0.87 Female -4.5±9.8 -0.55±2.6 -2.4±6.4 Smoking Yes 0.4±16 0.20 1.4±1.6 0.051 -2.6±15 0.92 No -5.2±8.5 -0.76±2.2 -2.3±4.1 Pain condition Yes 1.1±3.6 0.031 0.14±1.0 0.27 -.5±7.1 0.26 No -5.9±8.4 -0.76±2.1 -2.8±5.4 Marital status Single -4.63±9.2 0.058 -0.5±1.5 0.20 -1.7±4.3 0.040 Partner/married -7.7±6.9 -1.2±2.7 -4.6±6.0 Separated/widowed 0.55±12 0.38±2.8 0.55±6.2 Employed at time of fracture Yes 5.0±8.7 0.55 0.77±2.4 0.14 -2±5 0.34 No -2.9±13 0.50±2.0 -4.1±8.7 Years of education [r] -0.22 0.13 -0.34 0.012 -0.042 0.77 Immobilization Yes -5.7±9.2 0.19 -0.37±2.2 0.073 -2.7±4.2 0.49 No -1.9±9.4 -0.91±2.4 -1.4±8.8 Fracture location Agreement "no pain, no gain" -0.33 0.017 0.045 0.74 -0.13 0.37 Radial head fractures -4±8.3 0.42 0.63±2.6 0.75 -2.5±6.2 0.73 Distal radius fractures -6.2±11 0.42±1.9 -1.9±4.5 Other Variables [r] Days between injury and enrollment -0.17 0.23 0.061 0.66 0.076 0.59 Days between injury and final evaluation -0.31 0.025 -0.034 0.81 -0.18 0.19 Bold indicates statistically significant difference (P < 0.05); continuous variables as mean (±standard deviation). Pearson correlation indicated by r. Table options An increase in Whiteley Index scores was associated with less years of education (R = -0.34; P = 0.012). Changes in PCS scores were associated with marital status. Partnered or married patients showed a decrease in catastrophic thinking by an average of 5±6 points; single patients showed an average decrease of 2±4 points; separated or widowed patients showed an increase of 1±6 points (P = 0.040). Because no other variables were associated with changes in Whiteley Index or Pain Catastrophizing Scale, we omitted multivariable analyses Table 4. Table 4. Multivariable analysis change in symptom of depression score between 1 and 5 weeks after injury Change CESD score Regression coefficient (95% confidence interval) Standard error Pvalue Partial R2 Adjusted R2 Having an additional pain condition 5.8 (0.16 - 11) 2.9 0.049 0.078 0.26 Days between injury and final evaluation -0.23 (-0.39 - -0.067) 0.081 0.007 0.14 "no pain, no gain" agreement -1.2 (-2.1 - -0.35) 0.44 0.007 0.14 Bold indicates statistically significant difference (P < 0.05). CESD = Center for Epidemiologic Studies Depression Scale; WI = Whiteley Index