S. Goudie, M. McQueen, Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, UK D. Dixon, G. McMillan, Department of Psychology, University of Strathclyde, Glasgow, UK D. Ring, Dell Medical School, University of Texas at Austin, Austin, TX, USA.
Clin Orthop Relat Res. 2018 Apr;476(4):832-845. doi: 10.1007/s11999.0000000000000095.
Symptom intensity and magnitude of limitations correlate with stress, distress, and less effective coping strategies. It is unclear if interventions to target these factors can be used to improve outcomes after distal radius fracture in either the short- or longer term.
QUESTIONS/PURPOSES: (1) Are there any factors (including the use of a workbook aimed at optimizing psychological response to injury, demographic, radiographic, medical, or psychosocial) associated with improved Disabilities of the Arm, Shoulder and Hand (DASH) and Numerical Rating Scale pain (NRS pain) scores at 6 weeks after management of distal radius fracture? (2) Are any of these factors associated with improved DASH and NRS pain scores at 6 months after management of distal radius fracture?
We conducted a double-blind randomized controlled trial comparing a workbook designed to optimize rehabilitation by improving psychological response to injury using recognized psychological techniques (the LEARN technique and goal setting) versus a workbook containing details of stretching exercises in the otherwise routine management of distal radius fracture. Patients older than 18 years of age with an isolated distal radius fracture were recruited within 3 weeks of injury from a single academic teaching hospital between March and August 2016. During recruitment, 191 patients who met the inclusion criteria were approached; 52 (27%) declined participation and 139 were enrolled. Eight patients (6%) were lost to followup by 6 weeks. The remaining cohort of 129 patients was included in the analysis. DASH scores and NRS pain scores were recorded at 6 weeks and 6 months after injury. Multivariable regression analysis was used to identify factors associated with outcome scores.
At 6 weeks after distal radius fracture, when compared with an information-only workbook, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 38 [range, 21-48]; control DASH: 35 [range, 21-53]; difference of medians: 3; p = 0.949) nor NRS pain scores (workbook NRS: 3 [range, 1-5]; control NRS: 2 [range, 1-4]; difference of medians: 1; p = 0.128). Improved DASH scores were associated with less radial shortening (β = 0.2, p = 0.009), less dorsal tilt (β = 0.2, p = 0.035), and nonoperative treatment (β = 0.2, p = 0.027). Improved NRS pain scores were associated with nonoperative treatment (β = 0.2, p = 0.021) and no posttraumatic stress disorder (PTSD) (β = 0.2, p = 0.046). At 6 months, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 11 [range, 5-28]; control DASH: 11 [range, 3-20]; difference of medians: 0; p = 0.367) nor NRS pain scores (workbook NRS: 1 [range, 0-2]; control NRS: 1 [range, 0-2]; difference of medians: 0; p = 0.704). Improved DASH score at 6 months was associated with having fewer medical comorbidities (β = 0.3, p < 0.001) and lower enrollment PTSD (β = 0.3, p < 0.011). Lower NRS pain scores at 6 months were associated with having fewer medical comorbidities (β = 0.2, p = 0.045), lower enrollment PTSD (β = 0.3, p = 0.008), and lower enrollment Tampa Scale for Kinesiophobia (β = 0.2, p = 0.042).
Our study demonstrates that there is no benefit from the untargeted use of a psychological workbook based on the LEARN approach and goal-setting strategies in patients with distal radius fracture. Future research should investigate if there is a subgroup of patients with a negative psychological response to injury that benefits from psychological intervention and, if so, how best to identify these patients and intervene.
Level II, therapeutic study.
症状的严重程度和活动受限的程度与压力、痛苦和应对策略效果较差相关。目前尚不清楚针对这些因素的干预措施是否可以改善桡骨远端骨折患者的短期或长期结局。
问题/目的：（1）是否存在任何因素（包括使用旨在优化受伤后心理反应的工作手册、人口统计学、影像学、医学或社会心理因素）与桡骨远端骨折管理后 6 周时的残疾程度、手臂、肩部和手（DASH）和数字评分量表疼痛（NRS 疼痛）评分的改善相关？（2）这些因素中是否有任何因素与桡骨远端骨折管理后 6 个月时的 DASH 和 NRS 疼痛评分改善相关？
我们进行了一项双盲随机对照试验，比较了一种旨在通过使用公认的心理技术（LEARN 技术和目标设定）来优化康复的工作手册与仅包含伸展运动细节的工作手册在桡骨远端骨折常规管理中的效果。2016 年 3 月至 8 月期间，我们从一家学术教学医院招募了年龄在 18 岁以上、单独桡骨远端骨折的患者，招募时间在受伤后 3 周内。在招募过程中，有 191 名符合纳入标准的患者被接触，但有 52 名（27%）拒绝参与，最终有 139 名患者入组。8 名患者（6%）在 6 周时失访。其余的 129 名患者被纳入分析。DASH 评分和 NRS 疼痛评分分别在受伤后 6 周和 6 个月时记录。多变量回归分析用于确定与结局评分相关的因素。
在桡骨远端骨折后 6 周时，与仅提供信息的工作手册相比，使用心理工作手册并不能改善 DASH（工作手册 DASH：38 [范围，21-48]；对照组 DASH：35 [范围，21-53]；中位数差异：3；p = 0.949）或 NRS 疼痛评分（工作手册 NRS：3 [范围，1-5]；对照组 NRS：2 [范围，1-4]；中位数差异：1；p = 0.128）。DASH 评分的改善与桡骨缩短较少（β=0.2，p=0.009）、背侧倾斜较少（β=0.2，p=0.035）和非手术治疗相关（β=0.2，p=0.027）。NRS 疼痛评分的改善与非手术治疗（β=0.2，p=0.021）和无创伤后应激障碍（PTSD）（β=0.2，p=0.046）相关。在 6 个月时，使用心理工作手册与 DASH（工作手册 DASH：11 [范围，5-28]；对照组 DASH：11 [范围，3-20]；中位数差异：0；p = 0.367）或 NRS 疼痛评分（工作手册 NRS：1 [范围，0-2]；对照组 NRS：1 [范围，0-2]；中位数差异：0；p = 0.704）的改善均无相关性。6 个月时 DASH 评分的改善与合并症较少（β=0.3，p < 0.001）和入组时 PTSD 较低（β=0.3，p < 0.011）相关。6 个月时 NRS 疼痛评分的改善与合并症较少（β=0.2，p = 0.045）、入组时 PTSD 较低（β=0.3，p = 0.008）和入组时 Tampa 运动恐惧量表（β=0.2，p = 0.042）较低相关。
我们的研究表明，在桡骨远端骨折患者中，使用基于 LEARN 方法和目标设定策略的无针对性心理工作手册并没有带来益处。未来的研究应该调查是否有一部分对受伤有负面心理反应的患者从心理干预中受益，如果是这样，如何最好地识别这些患者并进行干预。
II 级，治疗性研究。
