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What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review

Jayakumar, Prakash, MBBS, BSc (Hons), MRCS (Eng), DPhil; Overbeek, Celeste L., MD; Lamb, Sarah, DPhil; Williams, Mark, DPhil; Funes, Christopher, MS; Gwilym, Stephen, FRCS(Orth), PhD; Ring, David, MD, PhD; Vranceanu, Ana-Maria, PhD

Clinical Orthopaedics and Related Research®: November 2018 - Volume 476 - Issue 11 - p 2190–2215
doi: 10.1097/CORR.0000000000000427
CLINICAL RESEARCH

Background Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.

Questions/purposes (1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients’ upper extremity injuries?

Methods We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the “upper extremity”, “outcome measurement”, and “impairment, psychological, social or symptomatic” variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.

Results Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.

Conclusions Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.

Level of Evidence Level IV, therapeutic study.

P. Jayakumar, S. Lamb, S. Gwilym, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Medicine, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK

C. L. Overbeek, Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands

M. Williams, Department of Sport and Health Sciences, Oxford Brookes University, Oxford, UK

C. Funes, Department of Psychiatry (Behavioral Medicine Service), Boston, MA, USA

D. Ring, The University of Texas at Austin, Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA

A.-M. Vranceanu, Massachusetts General Hospital and Harvard Medical School, Behavioral Medicine Program, Department of Psychiatry, Boston, MA, USA

P. Jayakumar, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK, email: pjx007@gmail.com

One of the authors (PJ) certifies that he received payments during the study period in the amount of less than USD 10,000 in personal fees as a consulting clinician from Johnson & Johnson, DePuy Synthes (New Brunswick, NJ, USA) outside the submitted work. One of the authors certifies that she (SL) received payments during the study period in the amount of less than USD 10,000 in personal fees as a consulting clinician/statistician from Pleuristem Inc (Tel Aviv, Israel) outside the submitted work. One of the authors (DR) certifies that he received payments in the amount of less than USD 10,000 in royalties from Skeletal Dynamics (Miami, FL, USA) and payments in the amount of less than USD 10,000 in personal fees from Wright Medical (Memphis, TN, USA), personal fees from Biomet (Warsaw, IN, USA), personal fees from Acumed (Hillsboro, OR, USA), personal fees from Illuminos (East Providence, RI, USA), personal fees as Deputy Editor for the Journal of Hand Surgery, personal fees as Deputy Editor for Clinical Orthopaedics and Related Research®, personal fees from universities and hospitals, and personal fees from lawyers outside the submitted work.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

This work was performed at The Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK.

Received February 28, 2018

Accepted July 12, 2018

© 2018 Lippincott Williams & Wilkins LWW
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