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

Returning to work – occupational therapists can help!

It’s not often that a really practical tool is published that works both as a guide to ‘what to do’ and as a marketing strategy for a profession. Today I want to introduce you to this guide to returning injured workers to work, developed by the Institute for Work and Health and two Canadian (Ontario to be precise) occupational therapy organisations.

The Institute for Work and Health is an independent, not-for-profit organization whose mission is to conduct and share research with workers, labour, employers, clinicians and policy-makers to promote, protect and improve the health of working people. The Institute operates with the support of the Ontario Workplace Safety & Insurance Board (WSIB). In addition to this core funding, the Institute receives grants from funding agencies such as the Canadian Institutes of Health Research, the US National Institutes of Health and the Social Sciences and Humanities Research Council of Cana (more…)

Return to work: Clinical judgements and evidence-based decisions

Followingon from yesterdays post – qualitative analysis of comments that rehabilitation providers made about factors they thought important and modifiable in helping an individual return to work.

For each factor that was analysed, the participants were asked ‘how and why is this factor important?’ Using ‘Leximancer’, a text analysis software, the relationships between various terms were mapped as shown above. For example, the three main words used were ‘Return’, ‘Work’, and ‘Injury’. The frequency of each word in relation to other words such as ‘Return’ and ‘Motivation, duties, help, impact’; ‘Workplace’ and ‘support, worker, injured’; and ‘Injury’ and ‘injured, employer, person’.

The authors describe the concept cluster of ‘Return’ which they interpret as reflecting ‘motivation to overcome difficult circumstances (as depicted by the concept terms ‘motivation, ‘negative’, ‘impact’) in returning to work (as depicted by the concept terms ‘job’, ‘return’, ‘person’), and the need to receive assistance to do so (as depicted by the concept term ‘help’). They suggest that this cluster of concepts was defined as ‘a process that was dependent upon the notion of engagement, supporting the injured worker to return to a more positive position through motivating relationships.’

The ‘Workplace’ cluster represented the need for a supportive workplace setting, or context, (‘workplace’, ‘worker’, ‘support’) and workplace involvement (‘time, ‘process’,‘employer’). This cluster of concepts was defined as a process that focussed on context, in that the workplace was a central point for rehabilitation and that a successful return-to-work would involve support for both worker and employer.

I think this would reflect most of our experience – and interestingly, this is an area not much studied in empirical studies. I expect that this is because of the complexity of the setting, and also the process focus rather than outcome focus of this aspect of intervention.

Two concepts that intersect all three clusters were ‘processes’, and ‘relationships’. This suggests that in all three areas, the way that people work together, and especially the need to follow through a series of actions to achieve the outcome. Again, neither processes nor relationships are often examined in detail in much rehabilitation research which focuses on ‘did the person return to work’?

Finally, this study analysed the ways in which the different participants classified predictors.
The following table illustrates some of the comments participants made: and agreement was not particularly high (Kappa 0.37), suggesting that different vocational rehabilitation professionals view various factors quite differently from each other.

My take on the lack of agreement between professionals is that we don’t really have a common model of work disability and rehabilitation, and commonly it seems that biomedical factors receive more attention than workplace factors, and employers are often left without significant guidance for them to achieve the level of support for the injured worker that is required.

I found this study to be very interesting – and apart from my criticisms that a larger group of participants from a wider range of backgrounds would have been helpful, and the thought that it would have been great to have had the opinions of people who have been through the process, both workers and employers, it helps develop the knowledge base in an area of rehabilitation that still seems somewhat under-developed.

Of course, another criticism is that this doesn’t reflect some of the changes that occur in dynamics between injured workers and their rehabilitation and employer relationships over time – especially if their return to work is delayed, or is taking longer than anticipated. But perhaps that’s a topic for a future study.

Muenchberger, H., Kendall, E., Grimbeek, P., Gee, T. (2007). Clinical Utility of Predictors of Return-to-work Outcome Following Work-related Musculoskeletal Injury. Journal of Occupational Rehabilitation DOI: 10.1007/s10926-007-9113-0