Patients with orthopaedic illness are at risk for persistent pain and disability. Successful recovery is more likely when patients engage in positive health and value-oriented behaviors, regardless of their pain level [26–28]. Although all patients have recovery as a goal, their approach to meeting this goal may be different. The regulatory focus theory [14, 15] provides a framework for understanding how patients with orthopaedic illness might approach their recovery process differently, depending on their individual values and beliefs. According to the regulatory focus theory, goal-oriented behaviors can be described as “promotion focused” or “prevention focused.” Promotion-focused behaviors are motivated by opportunities to gain or advance and are associated with positive thinking and chance-taking. In contrast, prevention-focused behaviors are motivated by avoidance of pain, the need for safety and security, and a thorough evaluation of what might go wrong. Someone with a promotion focus is eager to achieve positive outcomes (that is, playing to win), whereas someone with a prevention focus is more vigilant in order to avoid negative outcomes (that is, playing not to lose) [6, 17, 23]. According to regulatory focus theory, promotion focus and prevention focus are two separate dimensions that exist in all individuals [4, 17]. Individuals can employ both promotion- and prevention-focused behaviors in different circumstances, although they may gravitate towards one focus more than the other.
Patients with orthopaedic illness who are predominantly promotion-focused will approach recovery eagerly and focus on attaining prior levels of function and reengaging with their lives. They may be more likely to follow-up with medical recommendations to engage in physical or ocupational therapy exercises and activities of daily living, even when these are painful. Alternatively, patients who are predominantly prevention-focused may be likely to approach recovery vigilantly, prioritizing rest and avoiding pain for fear of further function loss. Fear of pain and painful movement are unhelpful and interfere with recovery-oriented behaviors [7, 9, 21, 28, 29]; therefore, individuals with higher levels of promotion focus might recover better than individuals with lower levels of promotion focus. Similarly, individuals with higher levels of prevention focus might recover more slowly than individuals with lower levels of prevention focus. Although regulatory focus theory is relevant to recovery after orthopaedic illness, no prior studies that we know of have examined regulatory focus theory in the context surgical or orthopaedic populations. Understanding the relationship between regulatory focus and recovery from orthopaedic illness may inform how medical providers communicate with patients to improve their recovery trajectory. We used the regulatory focus theory to examine whether regulatory focus is prospectively associated with improvements in pain and disability among patients with orthopaedic illness.
We therefore asked: Are improvements in pain intensity and disability over 6 months associated with a patient’s levels of promotion focus or prevention focus?
Patients and Methods
Participants and Procedures
The local institutional review board (IRB) approved this observational, longitudinal, prospective study. We enrolled 144 patients with any type of upper extremity orthopaedic illness (such as, acute or chronic, surgical or nonsurgical) at the hand and upper extremity service of a tertiary teaching hospital. Patients were included if they were 18 years or older, were literate in the English language, had access to email, and were able to provide informed consent. Patients were excluded if they were pregnant (per our IRB), had an active and untreated severe mental disorder by self-report, or planned to undergo surgery within the next 6 months at the time of enrollment. Allowing individuals who planned to undergo surgery within the time frame of this study to enroll would have confounded the results because surgery would have interrupted and shaped their recovery trajectory, including potential prescribed rest as necessary for healing. Patients were approached when they were waiting for their appointments, and informed consent was obtained from all patients before enrollment.
At baseline, patients completed questionnaires assessing pain intensity, disability, and regulatory focus, as well as demographic and clinical questionnaires. The 144 enrolled patients had a mean age of 51 ± 18 years and included 72 men and 72 women. Most patients self-reported their race as white (92%, 132 of 144) and living with a partner (60%, 86 of 144). The average length of education was 15 ± 3 years. The type and location of upper extremity orthopaedic illness widely varied in this heterogeneous sample, with trigger finger (16%, 23 of 144), carpal tunnel release (13%, 19 of 144), and carpal tunnel syndrome (5%, 7 of 144) as the three most commonly reported diagnoses. Thirty-one percent (44 of 144) of the patients were prescribed nonnarcotic pain medications, 38% (55 of 144) were prescribed narcotic medications. Forty-one percent (59 of 144) had trauma-related conditions, and 35% (50 of 144) had other pain in addition to their upper extremity condition.
Six months after enrollment, we sent patients encrypted emails with a secure link to questionnaires for pain intensity and disability. Each participant received a maximum of two emails and one telephone call reminder to complete the questionnaires before being considered lost to follow-up. Seventy-six percent (110 of 144) of patients completed the questionnaires at the 6-month interval (Table 1). Patients who were lost to follow-up were not different from those who completed the 6-month questionnaires in any of the descriptive variables including levels of promotion or prevention.
The Regulatory Focus Questionnaire
We measured regulatory focus using the Regulatory Focus Questionnaire . The Regulatory Focus Questionnaire comprises 11 items and assesses the two independent dimensions of regulatory focus: promotion and prevention. The promotion dimension is measured through six items asking about personal history of success and failure to pursue goals with a promotion focus (for example, “How often have you accomplished things that got you ‘psyched’ to work even harder?”). The prevention dimension is measured through five items asking about personal history of success and failure to pursue goals using a prevention focus (for example, “Growing up, would you ever cross the line by doing things that your parents would not tolerate?”). Continuous scores for promotion and prevention are derived separately by averaging the items for each dimension [4, 17]. Both subscales range from 1 to 5, with higher scores indicating a higher level of the measured dimension. The Regulatory Focus Questionnaire has demonstrated good internal consistency, test-retest reliability, and validity with promotion and prevention as orthogonal dimensions of regulatory focus .
We measured the intensity of upper extremity musculoskeletal pain using the 11-point Numerical Rating Scale (NRS) . Patients rated the intensity of their worst pain during the past week on a scale from 0 (no pain at all) to 10 (the worst pain they have ever experienced). The NRS is a validated measurement tool for subjectively assessing acute and chronic pain .
We measured disability using the QuickDASH , an 11-item measure that assesses upper extremity symptoms, the patient’s ability to engage in daily activities (such as household chores and carrying a shopping bag), and recreational and social functioning. Items are answered on a 5-point Likert scale. The total score is scaled and ranges from 0 (no disability) to 100 (highest disability) [2, 11]. The QuickDASH has excellent validity and reliability for assessing functional capacity for activities of daily living [2, 11].
We used means and SDs to describe continuous data. We performed a series of correlations, independent-sample t-tests, and one-way analysis of covariance (with Bonferroni corrections), as appropriate. Any variable with a significant (p < 0.05) correlation with the hypothesized mediators (promotion and prevention scores) or recovery outcomes (pain and disability scores) was identified as a potential confounding (that is, statistical control) variable.
Path analysis is an extension of multiple regression that is used to examine the causal relationship between a set of predictors and one dependent variable . We used this method to examine whether an individual’s recovery trajectory from baseline to 6 months is altered by the level of promotion or prevention. Path analysis allowed us to explore whether the two regulatory dimensions (levels of promotion and prevention) influence the direction (improvement or worsening) and magnitude (by how much) of pain intensity and disability over time. As opposed to simple regression, path analyses allowed us to specify the time ordering of our outcomes from baseline to 6 months and the influence of our two moderator variables in one model.
We ran two separate path models, one for each of our dependent variables: disability at 6 months and pain at 6 months. We used SPSS version 22.0 (IBM Corp, Armonk, NY, USA) with Hayes’ PROCESS macro version 2.16.3 (http://processmacro.org/index.html)—a versatile computational tool that allowed us to assess the effect of both moderators (promotion and prevention)—simultaneously . As illustrated in the first model for disability (Fig. 1A), we entered the levels of promotion and prevention as moderators, the level of disability at baseline as a predictor, and the level of disability at 6 months as the outcome.
For our research question, we calculated the effects of baseline disability on 6-month disability outcomes (path b1), the effects of regulatory focus on disability outcomes (promotion, path b2; prevention, path b3), and the potential moderating effects of promotion (baseline disability x promotion, path b4) and prevention (baseline disability x prevention, path b4) on disability over time (Fig. 1B). Moderation occurred when the level of the hypothesized mediator (the score for prevention or promotion) affects the magnitude of change in disability from baseline to 6 months (that is, a statistically significant interaction). We repeated the analyses in a separate path model for pain intensity.
To visualize the moderation, we graphed changes in disability over time separately for low (1 SD below the mean), medium (equal to the mean), and high (1 SD above the mean) levels of promotion or prevention. We followed methods recommended by Hayes and Cai . Finally, we determined the range of scores on the promotion or prevention subscales that were associated with significant improvements in pain and disability over time . Extreme levels of promotion or prevention beyond this cutoff were no longer expected to affect a patient’s recovery trajectory.
The negligible correlation between promotion and prevention (r = 0.04; p = 0.67) justified their entry as independent regulatory focus dimensions in the models (Table 2). The 37% (41 of 110) of patients who took narcotic pain medications at baseline reported higher pain (mean 2.80 versus 1.57; mean difference 1.23 [95% confidence interval 0.36 to 2.12]; p = 0.01; d = 0.56, medium effect) and disability (mean 28.10 versus 13.01; mean difference 15.09 [95% CI 6.59 to 23.59]; p = 0.001; d = 0.74, large effect) at 6 months than did those who did not. Women (49%, 54 of 110) reported more disability at 6 months than men did (mean 23.61 versus 13.84; mean difference 9.77 [95% CI 2.10 to 17.44]; p = 0.01; d = 0.48; small-medium effect). Therefore, we controlled for gender and narcotic use in the models. None of the other demographic or clinical variables were associated with pain or disability (Table 1).
For the preanalysis, we used common guidelines  for interpreting the size of correlations between continuous variables as negligible (Pearson correlation coefficent; r = 0.00 to 0.30), small (r = 0.30 to 0.50), medium (r = 0.50 to 0.70), and large (r > 0.70). We interpreted differences in our continuous variables by sample characteristics as small (Cohen’s d = 0.20), medium (d = 0.50), and large (d = 0.80). For the path analysis models, we interpreted small (change in the squared coefficent of multiple correlation due to interaction; ΔR2 = 0.008) and large (ΔR2 = 0.194) moderating effects . A change in QuickDASH score of 15  and NRS score of 2  from baseline to 6-month follow-up provided benchmarks for interpreting the minimal clinically important difference (MCID) in disability and pain intensity.
Are Improvements in Pain Intensity and Disability Over 6 Months Associated with a Patient’s Levels of Promotion Focus or Prevention Focus?
Among patients with upper extremity orthopaedic illness, higher levels of promotion were associated with greater improvement in disability after 6 months. In contrast, no association was observed between a patients’ level of prevention and their improvement in disability over this same period. Our path analysis of the regulatory focus dimensions showed that levels of promotion moderated improvements in disability over 6 months (ΔR2 = 0.02; F = 4.79; p = 0.03) with a small effect size, while levels of prevention did not (ΔR2 = 0.003; F = 0.90; p = 0.35; negligible effect size). The model as a whole explained 61% of the variance in patients’ disability trajectory over 6 months (R2 = 0.61; p < 0.001).
Patients with high promotion (n = 20, b = 0.284; p = 0.001) had the greatest improvements in disability after 6 months compared with patients with moderate (n = 73, b = 0.422; p < 0.001) or low (n = 17, b = 0.561; p < 0.001) promotion (Table 3). Holding baseline disability and prevention constant, high promotion was associated with nearly a 9-point improvement on the QuickDASH compared with low promotion (Fig. 2). Only 8% (9 of 110) of patients had extreme promotion levels that no longer correlated with disability, suggesting that this dimension of regulatory focus was positively associated with recovery from upper extremity orthopaedic illness in the majority of the sample (Fig. 3).
We did not observe an association between the regulatory focus dimensions and improvements in pain. Neither promotion (b = -0.22 [95% CI -0.48 to 0.04]; p = 0.09) nor prevention (b = -0.04 [95% CI -0.15 to 0.24]; p = 0.65) moderated improvements in pain over 6 months.
Regulatory focus theory characterizes the way in which individuals engage in goal-oriented behaviors, yet it has not previously been applied to the context of recovery from orthopaedic illness. We applied the regulatory focus theory framework to patients with an upper extremity orthopaedic illness to see whether the relationship between regulatory focus and recovery can provide novel insight into strategies to improve patients’ recoveries. We investigated whether improvements in pain intensity and disability over 6 months were associated with a patient’s levels of promotion focus or prevention focus. We found that a patient’s level of promotion focus was associated with improvements in disability over 6 months and that their level of prevention focus was not. Although the effect size for the role of prevention was small, this was calculated over and above baseline disability level, which explained the largest amount of variance in disability at 6 months. Neither of the regulatory focus dimensions were associated with improvements in pain during this same period. In line with the regulatory focus theory tenets, these findings suggest that orthopaedic surgeons can improve patients’ recovery trajectories by speaking to patients’ promotion focus, framing disability recovery as a positive opportunity for improved functioning and encouraging patients to take chances in engaging in recovery behaviors. Similarly, messages crafted to address prevention focus (for example, providing reassurance) may not offer the same benefit for improving disability.
There are several limitations to our findings. First, our results cannot be generalized to orthopaedic patients who do not have an upper extremity musculoskeletal illness. Second, our patients were mostly white, living with a partner, and well-educated, which limits the generalizability of our findings to more diverse populations. Third, we lost 24% of enrolled patients to follow-up. It is possible that patients retained at follow-up differed from patients lost to follow-up with respect to some variable that we did not measure, which might impact recovery, introducing a potential confound into our analysis. Fourth, we did not investigate whether the type of upper extremity orthopaedic condition or anatomical location of injury was associated with a different relationship between regulatory focus and recovery. Although prior research has not shown differences according to these variables on psychosocial constructs and recovery, future studies should use larger samples to allow for these comparisons. Fifth, despite controlling for narcotic use and gender in our models, there could be other psychological or clinical variables that affect recovery that we were unable to measure. For example, regulatory focus theory posits that depression occurs due to chronic self-regulatory failure within the promotion system while anxiety occurs due to chronic self-regulatory failure in the prevention system [19, 24]. This means that individuals with depression fail to experience rewards when engaging in promotion behaviors and thus stop pursuing them. In contrast, anxious individuals fail to perceive success in avoiding danger, and become hypervigilant over time to maintain safety [19, 24]. Although examination of depression and anxiety was beyond the scope of the current research, future studies should investigate the association of regulatory focus, depression, and anxiety in the context of recovery after orthopaedic illness.
Several other limitations are relevant to the interpretation of our findings. Our study design only encompassed a 6-month follow-up assessment. Although this represents a period in which recovery can occur, we cannot make conclusions regarding the durability of the association between regulatory focus and recovery. Finally, the degree to which regulatory focus is modifiable is not fully known. Regulatory focus is typically conceptualized as an innate predisposition of people’s approaches to pursuing goals, rather than as a modifiable construct. However, the fact that people can display both promotion-focused and prevention-focused behaviors in different contexts illustrates how most people have the capacity to pursue goals from both a prevention and promotion focus to some degree. This suggests that medical providers may be able to influence patients’ approaches by speaking more strongly to one perspective over the other. Our findings offer only preliminary evidence that regulatory focus is relevant to recovery from upper extremity musculoskeletal illness.
Promotion Focus Associated with Lower Disability Levels
We found that patients’ levels of promotion focus were associated with improvements in disability over 6 months, with higher promotion associated with better recovery. Patients with high promotion showed nearly a 9-point difference in improvement on the QuickDASH compared with patients low promotion. Although lower than the MCID associated with rehabilitation (15-point QuickDASH reduction from physical therapy ), promotion focus emerged as a meaningful psychological correlate with disability recovery. These findings have important implications for the clinical care of patients with an upper extremity musculoskeletal illness. Although regulatory focus theory posits that speaking to patients in alignment with their natural predominant regulatory focus is the best way to increase their commitment to their recovery goals [4, 16], our findings suggest that promotion focus matters more than prevention focus in this orthopaedic population. The manner in which surgeons communicate with patients about diagnoses and recovery trajectories could be framed as either promotion- or prevention-focused, depending on the specific recommendations that a surgeon emphasizes and the tone of his or her communication style . For example, a surgeon who discusses recovery in a cautious and negative tone and makes recommendations to avoid further damage and loss of function would appeal to a patient’s prevention focus. In contrast, a surgeon who discusses recovery in an enthusiastic and positive tone and encourages a patient to engage in positive health activities regardless of pain to achieve maximum recovery and return to baseline would appeal to the patient’s promotion focus. Our findings suggest that speaking to a prevention focus, even to correct the patient’s prevention focus, will not correlate with recovery. To maximize patients’ improvements in disability over time, medical professionals should speak to the promotion-focused side of all patients, regardless of their levels of promotion versus prevention focus. Such efforts show promise in encouraging patients to take an active role in their recovery and override pain signals to pursue positive health behaviors .
Promotion and Prevention Focus Not Associated with Pain Levels
Interestingly, we did not find an association between the level of a patient’s prevention or promotion focus and pain levels 6 months after diagnosis. Unlike disability, which is measured primarily as a behavioral construct comprising the specific activities that people perceive that they are able to engage in or not, pain intensity is primarily an emotional construct. As such, it makes sense that engagement in a goal-oriented behavior consistent with an individual’s regulatory focus would be associated with disability and not pain intensity. Future research should investigate other psychological factors (such as, depression, anxiety, and pain catastrophizing) as targets for decreasing pain intensity.
Our findings support a simple and practical recommendation, one that may help patients to recover more fully from upper extremity musculoskeletal illness. Patients with higher levels of promotion focus recover better from musculoskeletal illness. Further, increasing levels of promotion focus were associated with increased improvements in disability for patients with upper extremity illness, regardless of their initial promotion focus scores. Orthopaedic surgeons and medical professionals working with this population can appeal to the promotion-focus side of patients by framing recovery in a positive and enthusiastic tone, emphasizing recovery as an opportunity for improved functioning, and encouraging patients to take chances, such as engaging in therapy exercises despite pain. Based on the current evidence, we believe that appealing to patients’ promotion-focus side will be primarily effective for patients without depression and anxiety. Patients with depression and anxiety may have chronically altered regulatory focus, and would need a higher level care to directly target these symptoms. Yet for most patients presenting to orthopaedic practices, when medical professionals align their speech with a promotion-focus, patients are more likely to engage in positive health behaviors regardless of their pain level and to be persistent and courageous in their pursuit of recovery.
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