Recovery of Comfort and Capability after Upper Extremity Fracture is Predominantly Associated with Mindset: A Longitudinal Cohort from the United Kingdom

Abstract

To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures. Design: Secondary use of longitudinal data. Single level-1 trauma center in Oxford, United Kingdom. English speaking adults with isolated proximal humerus, elbow or distal radius fracture managed operatively or non-operatively were included, and those with multiple fractures or cognitive deficit were excluded. Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2-4 weeks, and 6-9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on AO/OTA classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture related aspects. Among 703 included patients (59 ± 21 years old, 66% women, 16% high energy injury), four statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: β=4.1, 3: β=7.5, 4: β=17) and pain intensity (group 3: β=0.70, 4: β=1.4)(p<0.01). Higher fracture severity (β=4.5), high energy injury (β=4.0), and nerve palsy (β=8.1) were associated with worse baseline incapability (p<0.01), and high energy injury (β=0.62) and nerve palsy (β=0.76) with worse baseline pain intensity (p<0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (β=1.3, β=7.0) and pain intensity (β=0.19, β=1.1)(p<0.02). Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.