Recovering from a wrist or ankle fracture: pain-related fear, catastrophising and pain influences outcome
I have no idea how many wrist and ankle fractures occur every year, but I can bet it’s not a small number by any imagination. For most of us, I’m guessing we’d expect to have a fracture, wield a wonderfully-autographed cast, get it removed and go on our merry way – but after reading this article, and having seen some very sad people over the years, perhaps my expectations of speedy return to normal might be over-inflated!

This paper by Linton and colleagues from Orebro, Sweden, is a novel one in that most of our knowledge about chronic pain comes from observing people recovering from low back pain. After all, low back pain is one of the most common pains, it’s the one that produces the most long-term work disability, and treatments for it eat up health budgets like little else. BUT, in a fracture, we have a nice clear-cut incident that begins the process of recovery, a well-known pathophysiology, and a well-understood recovery process from a biophysical perspective, so it provides us with a great opportunity to see what the risk factors are for longterm pain and disability.


I’ll just briefly describe the methodology here – 79 participants were sequentially recruited to the study if they had a distal fracture, were aged between 18 – 70 years, without any other fractures and not experiencing dementia. Nine dropped out and these were older and female. Each participant completed a modified Fear Avoidance Beliefs Questionnaire, completing this in respect of their beliefs about pain before their injury; the Pain Catastrophising Scale, numeric rating scale for pain before the injury, expected recovery at six months, and actual recovery at six months. Mobility and strength were also tested a time one and six months later.

Pain and worry reduced over time, as expected. Pain level started at 4 (ranging between 0 – 8), and dropped at T2 and T3. The number of people reporting no pain or no worry increased from T1 to T3 from 4% to 46% and from 30% to 57%.
69% of patients thought they should be fully recovered within six months when they were first asked. 36% thought this at T2, but the percentage who actually thought they were fully recovered at T3 were only 29%. That means that although most people thought they would be recovered within 6 months, actually less than 1/3 actually were. I certainly didn’t expect that!

Mobility and strength ratings at T3 showed 45% were not fully recovered at six months if they had a wrist fracture, while 33% of people with ankle fractures were not fully recovered. And yes, they do describe the processes used to measure mobility and strength.

Looking at fear-avoidance and catastrophising, there was a bit of work to get the groups divided into high and low levels of fear.
The proportion of patients with low fear at T1 and T2 was 54%, while for catastrophising was 56%. 29% of the participants had a high fear and pain profile at T2. What this lead to, after looking at an odds ratio analysis examining the relationship between fear and catastrophising, was that higher fear-avoidance beliefs increased the risk for pain , but high fear wasn’t significantly related to future self-rated recovery, mobility or strength. For catastrophising, there was a relationship only for strength.

What can we conclude?
OK, apart from the small sample size, and the need to use the strength of the noninjured limb as a substitute for the fractured one at T1, and the authors suggest that taking more frequent repeated measures might have helped; we can conclude a couple of interesting things:

  1. People over-estimate how rapidly they will recover from distal fractures, and expect to be fully recovered within six months, when 2/3 of people won’t be
  2. Higher-than-average scores, or increasing scores on pain-related fear and catastrophising are linked with future pain and recovery levels.  This is similar to the repeated findings in back pain and other types of pain, so shouldn’t be unexpected.
  3. As catastrophising and pain-related fear drop over time, this could mask those who are at risk of failing to recover.

Linton and colleagues suggest that close monitoring of fear-avoidance beliefs and catastrophising over the first few weeks of recovery would help health professionals intervene with psychological input designed to reduce fear and normalise expectations.  In other words, reassure patients that it’s normal for distal fractures to take a lot longer than 6 months to fully settle down.

One problem with this for me is that I don’t know anywhere in New Zealand where fear-avoidance and catastrophising is measured in people who have distal fractures! Most orthopaedic departments are singularly lacking in psychologists, and provided the fracture is uniting, patient’s fears and worries rarely get a look-in!  I can’t speak for GP’s who might have some ongoing input with a person who has a distal fracture, but I’d expect that unless the person attends and asks for help, their worries and fears won’t be identified.  This then means the physiotherapist who might be involved to help improve function (and maybe the occupational therapist) are the ones who may be left trying to address the patient’s fears.

Do we need to introduce another layer of psychological input delivered by psychologists for this group of people?

I think not – I do think maybe occupaitonal therapists and physiotherapists could be mindful of the natural healing process, the time it takes to recover, and be aware of how fear-avoidance and catastrophising interact to produce disability – and start to structure graded activities to increase the  confidence a person can have in their own ability to move.  And perhaps encouraging gradual return to functional activities rather than ‘exercises’ per se could be a better approach.  No gadgets please OT’s!  Learning to use the limb, attending to fear and catastrophising and addressing these quickly are well within the clinical skills of occupational therapists, physiotherapists, nurses and GP’s – so watch, listen and respond, even in these acute and so-called ‘simple’ injuries.

Linton, S., Buer, N., Samuelsson, L., & Harms-Ringdahl, K. (2010). Pain-related fear, catastrophizing and pain in the recovery from a fracture Scandinavian Journal of Pain, 1 (1), 38-42 DOI: 10.1016/j.sjpain.2009.09.004

‘Psychosocial’ – is it Pandora’s box?
I’ve been reading a paper written by Cam Crawford about GP’s use of the ‘Yellow Flags’, or psychosocial risk factors for identifying ‘at risk’ patients. It seems clear from his sample of GP’s that few of them are comfortable with the Guidelines as they are presented – and that their discomfort arises for quite a few reasons.
Crawford identifies that many GP’s don’t have time (or inclination) to read guidelines that pass across their desks. Some don’t like the rehabilitation model that ACC works from, and the ‘Yellow Flags’ Acute Low Back Pain guideline is strongly identified with ACC’s model. Some GP’s don’t identify themselves as working within a biopsychosocial model and firmly believe they must attend to the biomedical factors first – and consider psychosocial factors only after progress is slow.

Many of those in this study thought that their professional perspective and ‘gut feeling’ was sufficient to enable them to identify ‘at risk’ patients, and thought that using an ‘artificial’ structure such as the algorithm presented in the Acute Low Back Pain Guidelines was an attempt to place people into boxes – and people are too complex for this. Finally, most GP’s found that time constraints limited both their initial reading of the ‘Yellow Flags’ and their comfort and confidence in identifying and discussing psychosocial risk factors with their patients.

Unfortunately, I don’t believe the findings of Crawford and colleagues is very different from those we would find amongst physiotherapists, chiropracters, osteopaths or occupational health nurses – all of whom work with people who have acute low back pain. Somehow the confidence and comfort people have with the idea of nonmedical factors influencing recovery from acute low back pain is very very low.

I’ve heard people talk of the fear of ‘opening Pandora’s box’ if they ask about family relationships, mood, beliefs about the problem, work and so on. Fear that the problems may just be too big to fit into a brief clinical encounter. Fear that the person might need more clinical skill to unpack the person’s concerns…

I wonder how true this is? Yes, it does take a little time to ask about some of these things – but is it really a time factor, or could there be something more fundamental making it something to be wary of? Could it be that when we’re busy, it’s easier to disengage our emotions, to restrict our listening to things that are clear-cut and non-emotive? Do we fear hearing about someone else’s concerns because it might mean we are prone to them too?

I don’t know the answers – and over the next few days I want to explore this because if we are to reduce the number of people progressing to chronic disability, the risk factors that are well-known need to be identified and effectively managed. Now we might not have great management of them yet, but we do know how to identify them. And that’s a start.

Cameron Crawford, Kathleen Ryan, Edward Shipton (2007). Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain The New Zealand Medical Journal, 120 (1254), 1-13