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The Impact of Depression and Pain Catastrophization on Initial Presentation and Treatment Outcomes for Atraumatic Hand Conditions

London, Daniel A. BA1; Stepan, Jeffrey G. BS1; Boyer, Martin I. MD, FRCS(C)1; Calfee, Ryan P. MD, MSc1

Journal of Bone & Joint Surgery - American Volume: 21 May 2014 - Volume 96 - Issue 10 - p 806–814
doi: 10.2106/JBJS.M.00755
Scientific Articles

Background: Prior studies have suggested that patient-rated hand function is impacted by depression and pain catastrophization. We studied the impact that these comorbidities have on treatment outcomes.

Methods: Two hundred and fifty-six patients presenting to an orthopaedic hand clinic were followed in this prospective cohort investigation. Patients who were prescribed treatment for atraumatic hand/wrist conditions were eligible for inclusion. At enrollment, all patients completed the Center for Epidemiologic Studies Depression (CES-D) scale, the Pain Catastrophizing Scale (PCS), and the Michigan Hand Outcomes Questionnaire (MHQ; scale of 0 to 100, with 100 indicating the best hand performance). One month and three months after treatment, patients again completed the MHQ. Participants’ psychological comorbidity status was categorized as either affected (a CES-D score of ≥16, indicating depression, or a PCS score of ≥30, indicating catastrophization) or unaffected (a CES-D score of <16 and a PCS score of <30). Diagnoses and treatments for both the affected and unaffected groups were examined. The effect of time and patient status, and their interaction, on MHQ scores was evaluated by mixed modeling.

Results: Fifty patients were categorized as affected and 206 as unaffected. Diagnoses and treatments differed minimally between the two groups. At the time of enrollment, the mean MHQ score of the unaffected group (64.9; 95% confidence interval [CI], 62.5 to 67.3) was significantly higher than that of the affected group (48.1; 95% CI, 43.3 to 53.0). Both groups demonstrated similar significant absolute improvement over baseline at three months after treatment (an increase of 12.5 points [95% CI, 7.5 to 17.4] in the affected group and 12.8 points [95% CI, 10.4 to 15.3] in the unaffected group). Thus, at the time of final follow-up, the rating of hand function by the affected patients (60.6 [95% CI, 55.0 to 66.2]) was still significantly poorer than the rating by the unaffected patients (77.7 [95% CI, 75.0 to 80.5]).

Conclusions: Although patients affected by depression and/or pain catastrophization reported worse self-rated hand function at baseline and at the time of follow-up, these patients showed similar absolute improvement in self-rated hand function following treatment compared with patients with unaffected status.

Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

1Washington University, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address for R.P. Calfee:

Investigation performed at Washington University, St. Louis, Missouri

A commentary by Fraser J. Leversedge, MD, is linked to the online version of this article at

Copyright 2014 by The Journal of Bone and Joint Surgery, Incorporated
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