Written by: Gillian Gavaghan, BScOT
Virtual Hand to Shoulder Fellow ‘20
Dublin, Ireland
Introduction
Are you a glass half full or glass half empty person? Perhaps in my naivety, I determined that these predisposing personality traits dictate our response to unexpected situations.
How would you deal with a loss of function or disability due to an acute injury?
1. Glass half full: View it as an opportunity to take a break, to re-group, to catch up on all the series on Netflix you haven't quite been able to binge-watch over your weekend breaks from work or
2. Glass half empty: View it as something simply catastrophic – the biggest inconvenience imaginable interfering with your work, your hobbies, and the goals you had set for yourself
Having recently fallen victim to an unfortunate injury, I could firmly place myself in the latter category [of course, still making time for multiple Netflix binges between the waves of thinking ‘why such bad luck’ (*the more colorful language used at the time has been censored!)]. My injury meant not being able to move without pain for what felt like an eternity (it was *only* 3 weeks), not being able to sleep due to the aforementioned pain, not being able to work, and facing up to or beyond half a year without being able to participate in all of what is meaningful and important to me.
During this time of heightened emotion, it did get me thinking about how my feelings of relative despair and hopelessness echo the sentiment of some of my patients during those first few weeks of treatment where a return to normality seems like an impossible reality.
As the occupational therapists reading this will recall, the profession's philosophical base suggests that health and well-being are intricately linked to participating in daily occupations (Kielhofner, 2008). The loss of function in an upper limb immediately interferes with ones’ ability to perform tasks as one once did. The environmental demands or the established roles, responsibilities, and routines do not change as quickly as the loss of function can happen. This can have devastating consequences for the well-being of the patient.
I was keen to explore this topic a little further – to develop a better understanding of the psychological impact of trauma and identify methods of supporting these patients grounded in an evidence base.
What is the psychological impact of injury, and how does it affect us?
Paul Brand, the author of 'The Gift of Pain,' concluded that
‘‘...what is beyond doubt the most important factor in hand therapy: the patient’s will to recover. The mind, not the cell of the injured hand will determine the final extent of rehabilitation, because without strong motivation the patient simply will not endure the disciplines of recovery” (Schindeler & Stegink-Jansen, 2011)
These words embody the belief that the psychological status of the person directs the path of rehabilitation.
Physical rehabilitation strategies are well represented in the hand therapy literature, but there has been little direct examination of traumatic upper limb injuries' psychosocial impact. The umbrella term ‘‘stress’’ refers to a situation that may threaten the individual’s internal sense of balance or homeostasis. The regulatory system then becomes unbalanced. A stress reaction occurs when an event or change is deemed threatening and exceeds the individual’s ability to respond healthily (Schindeler & Stegink-Jansen, 2011).
Bear-Lehman & Poole (2011) succinctly describe that the signs or symptoms of stress reactions can be categorized into three subsystems: intrusion, avoidance, and hyperarousal. Intrusion, or the sense of perceiving the hand injury and all the requirements for recovery as an unwelcome addition to one’s life, can be expressed in the form of intrusive thoughts, nightmares, flashbacks, and negative feelings. Avoidance behavior manifests in self-restriction or self-limitation of activity engagement, such as to avoid watching wound dressing changes, hiding the hand, or not complying with the home exercise program. Those individuals who present with a hyperarousal stress reaction tend to present as angry, with extreme caution, mood changes, and increased irritability. Additionally, the patient’s capacity to cope and adapt to a changed functional status or cosmetic appearance, re-experiencing the traumatic experience, dependency on others, involuntary inactivity, or uncertainty about the future can exacerbate stress reaction levels and impede recovery.
Among the athlete population, injury is often accompanied by depression, tension, anger, and low self-esteem, particularly in highly competitive, seriously injured athletes. Mood disturbance relates to the athlete's perceived progress in rehabilitation and has been shown to negatively relate to attendance at rehabilitation sessions (Smith, 1996). It was hypothesized by Johnston & Carroll (2000) that those who were more involved in sport before injury would exhibit a greater emotional response to injury. This response appears to have largely the same affective impact for those with minimal and considerable involvement in sport and exercise before injury.
Psychosocial triggers may be manifesting as biomechanical problems (Smith, 1996). Psychological factors interact with physical aspects of injury in rehabilitation to complicate treatment and delay recovery. A growing body of evidence relates psychological well-being and physical health. This suggests that athletes and any patient who overreacts to injury may have a longer recovery time (McClay & Levitt, 1991). A tendency toward negative thinking and assessment of life situations may translate into a similar evaluation of the pain condition. All of this may convert into reports of increased pain and disability (Vranceanu & Ring, 2008). On self-appraisal, levels of stress correlate with disability levels – as stress reaction increases, the perceived disability also increases. This could impede an individual's capacity to participate in the therapy process fully. (Bear-Lehman & Poole, 2011).
What Can We Do Better?
The scope of this blog does not permit in-depth details about specific interventions. However, I have shared two key concepts grounded in an evidence base and may enhance our treatment of patients with consideration for their real-life demands and challenges in the context of their upper limb injury.
When it comes to interventions, clinical skill and judgment are used to identify which approaches best meet the patients' needs at a particular point in their rehab journey. A greater breadth of tools gives the therapist a broader battery of equipment to support the dynamic needs of a varied client group. Therefore, I have signposted some interventions you may wish to develop further to enhance your toolkit.
1. A Holistic Approach
The Framework
The assessment of the person should be embedded in the theoretical background of the profession of occupational therapy. The assessment should have a biopsychosocial approach rather than a pure biomechanical model, which is traditionally used in the treatments of musculoskeletal problems. A review of the person should go beyond the athlete on the field or the activity which caused this injury. Our reticence in discussing psychosocial issues (including sleep problems, perceptions of pain, and disability) may contribute to a focus on pathophysiology to the exclusion of other aspects of illness behavior (Vranceanu & Ring, 2008). A well-rounded assessment may enable the therapist from early on to identify potential barriers to rehab and allows us to assess if other components are contributing to musculoskeletal healing and return to ADLs. By understanding the importance and value placed on specific tasks in a persons’ life and their new inability to engage in the same, we can anticipate that there will be a significant psychological burden with their injury (Johnston & Carroll, 2000). This knowledge may support the therapist in meeting the patient's needs most appropriately through the rehab journey.
The biopsychosocial model emphasizes that pain may be best characterized according to complex interactions among biological, psychological, and social variables (Vranceanu & Ring, 2008). For clinicians, greater awareness, understanding, and appreciation of the power of psychologic influences on illness will support patients to become more receptive to discussing and treating this aspect of their illness (Malette & Ring, 2006).
The Assessment
There are many advantages to assessing the psychosocial factors in patients with upper limb pain. Screening for these factors and subsequent treatment may improve surgical outcomes and may prevent the transition toward chronic pain syndromes (Vranceanu & Ring, 2008). Identification and treatment of inadequate coping strategies and other psychosocial factors is essential to the health of patients with upper extremity illness (Braun et al., 2016).
This is not an exhaustive list of assessment tools but could be a useful starting point.
The Impact of Events Scale-Revised (IES-R)
o Parallels the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for posttraumatic stress disorder (PTSD)
o One of the most widely used self-report measures of stress after trauma
o Shown to be a valid tool when administered within seven days after a specific traumatic life event with strong test/retest reliability (Bear-Lehman & Poole, 2011).
The QuickDASH and the DASH
o Routinely used to assess perceived disability with upper limb function
o Strong test/retest reliability
o Used in a plethora of research papers related to this topic (Bear-Lehman & Poole, 2011; Vranceanu & Ring, 2011)
The Pain Catastrophizing Scale
o A reliable and valid measure of negative, pain-related conditions
o Higher scores represent more catastrophizing (Vranceanu & Ring, 2011)
o A tendency toward negative thinking and appraisal of life situations may translate into a similar appraisal of the pain condition – this may convert into reports of increased pain and disability (Vranceanu & Ring, 2011; Vranceanu & Ring, 2008; Watson & Ring, 2008)
Centre for Epidemiologic Studies-Depression (CES-D)/Beck Depression Inventory/ Health Anxiety Inventory
o Measurement of depressive traits (not seeking to make a clinical diagnosis of depression) helps the therapist anticipate how a patient may respond to their disability, hence highlighting the approach or type of intervention which may be most suitable for that person
o The therapist can use an awareness of the correlation between stress and disability to help the patient develop more effective coping strategies, adapt to their injury, and learn how to engage in the therapy process, thereby improving outcomes (Vranceanu & Ring, 2011; Watson & Ring, 2008; Vranceanu & Ring, 2008).
2. Communication:
The empathy we share with our patients is the building block of trust and rapport and the foundation for effective communication (Schindeler & Stegink-Jansen, 2011). Words facilitate communication, but they also shape our beliefs, behaviors, feelings, and actions. Effective communication is the basis of our care within the clinical setting, providing verbal instructions, or written home instructions. The words we chose to use may powerfully influence, either positively or negatively, a patient's perception and interpretation of their pain and recovery and how they cope with their illness or disability (Vrancenau, Elbon & Ring, 2011; Schindeler & Stegink-Jansen, 2011). It may be as essential to ensure that the patient feels heard and cared for to provide expert medical advice (Vranceanu & Ring, 2011). We need to train ourselves to communicate with language that encourages increased health and wellness (Ring, 2011).
Words with negative emotional content can affect patients' beliefs about their medical complaints and their treatment and recovery expectations. Frame the illness in the most positive, optimistic, enabling, and practical way that is consistent with current evidence. Careful and precise terminology with neutral or positive emotive content may improve a patient’s well-being, optimism, resilience, and self-efficacy. It is generally important to pick the most positive words—whether we use them to name or describe a condition, give treatment recommendations, or generally communicate with patients (Vrancenau, Elbon & Ring, 2011).
More information about the effect of words in the English language can be found at this link: https://www.uvm.edu/pdodds/teaching/courses/2009-08UVM-300/docs/others/everything/bradley1999a.pdf
Allow the patient to provide a narrative for their presenting complaint. Hand therapists can yield valuable information from rich patient narratives, facilitated by attentive listening. The patients’ explanation of their complaint is the basis for achieving mutually accepted explanations of illness and treatment plans. The words that patients choose as their narratives can provide important clues to their personality types as outlined by the Myers Briggs Type Indicator profiles. Determining a personality type is not a means to identify or treat a psychological disorder, but rather identify the patients’ learning preference. This can help the therapist work successfully with each patient by communicating with them most effectively (Moorhead et al., 2011).
Some practical ways the therapist can support the different personality traits:
Extravert
Schedule with other patients/overlapping appointments.
Benefit from external motivation.
Introvert
Schedule 1:1 appointments. Benefit from more time to think/talk/act.
Sensing
Utilize exercise with very clear linear progression.
Allow repetition.
Intuiting
Able to view the 'big picture'. Able to understand how novel ideas may relate to their rehab.
Thinking
Back up therapy with evidence
Feeling
Make optimal progress if they feel that the therapist cares about them and is working with them in the context of their values
Judging
Have clearly outlined expectations and provide feedback to these patients
Perceiving
Give choices and options through their rehab journey.
3. The Interventions
Coaching
o Teunis et al. (2016) concluded in their research the hypothesis that coaching may reduce the impact of catastrophic thinking on the recovery process.
o The key elements of coaching are empathy with the difficulty of the recovery process; normalization of the counterintuitive aspects of recovery; having the patient take an active role in their recovery, and description of the recovery process using positive words and analogies and being careful to avoid concepts that might reinforce catastrophic thinking.
o This type of coaching is combined with information about the injury, replaces lengthy technical descriptions of the injury and recovery process, and addresses the most common patient concerns.
o Those more involved in sport may have greater information needs than those less involved and experience confusion when such needs are not met (Johnston & Carroll, 2000).
Positive reinforcement
o Impart the thinking that the current situation is modifiable. Reassure the patient with the evidence that they will feel better with time – the negative emotional impact of injury diminishes over the course of rehabilitation (Johnston & Carroll, 2000).
o Replace hyperreactivity with thinking based on science (Ring, 2011). Educate our patients on their injury, the healing time frames, and what their body is doing to prepare them to return to their meaningful ADLs.
o Overestimation of injury was found to be significantly associated with reported pain and other adverse psychological reactions, including anxiety, anger, and low self-esteem (McKay & Levott,1991).
Support and identify new routines
o Health and well-being is intricately linked to participating in daily tasks (Kielhofner, 2008)
o Where appropriate, provide alternates for aerobic or other activities to maintain physical and mental well-being when faced with an injury. Those more involved in sport and exercise may require more information about alternative activities to maintain aerobic fitness (Johnston & Carroll, 2000).
Positive self-talk
o This has been shown to be a valuable intervention (Smith, 1996).
o Relaxation
§ This provides the person with a non-threatening way to begin treatment (Smith, 1996; McClay & Levitt, 1991)
o Stress management (McClay & Levitt, 1991)
o Goal setting (Smith, 1996)
o Healing imagery (Smith, 1996)
Closing thoughts and take-home messages
Evidence does indeed suggest that predisposing personality traits may determine our response to upper limb trauma. People who tend to catastrophize tend to have higher levels of perceived pain and disability.
Clinically, we can practice in a manner that incorporates an appreciation for the impact of the biological, psychological, and social components in a persons’ life. This is a step away from the traditional biomechanical or medical model applied in orthopedics; however, it reflects the theoretical frameworks embedded in the practice of occupational therapy. Through education, psychosocial support, and functional training, therapists can enable patients to meet their goals by promoting self-efficacy (Braun, 2016).
As written by Schindeler & Stegink-Jansen (2011), the mind will determine the trajectory of rehab. Accurate assessment of the persons’ psychological status is a tool we can use to identify the severity of a persons’ stress. This enables the correct selection of communication style, particularly when paired with the knowledge of the persons' different personality traits, allowing the therapist to select the best-matched skills and tools to maximize that persons’ rehab outcomes.
Communication style, or more specifically, the use of words, is consistently identified as a means by which clinicians can either escalate or de-escalate a persons’ psychological response to their injury. The words we use may dictate the persons’ perception of their injury and thus, their perceived prognosis. Coaching is identified as a useful intervention to reduce catastrophic thinking. Using factual and scientific evidence of healing timeframes helps to manage expectations and supports the patients self-talk and positive reinforcement that this acute phase of injury will end and that they will feel better than they currently do, in time.
I can attest to the anecdotal commentary that time is a healer. Eight weeks post-injury and I can sleep, move independently, and have returned to work. The return to my hobbies is quite some time away, but the psychological burden of injury has certainly been much reduced with the focus on the things that I am now able to do.
I am glass half full! 😊
References
1. Bear-Lehman, J., & Poole, S.E. (2011) The Presence and Impact of Stress Reactions on Disability among Patients with Arm Injury, Journal of Hand Therapy, 24:89-94
2. Braun, Y., Melemma, J.J., Peters, R.M., Curley, S., Burchill, G., & Ring, D. (2016) The relationship between therapist-rated function and patient-reported outcome measures, Journal of Hand Therapy, 30: 516-521
3. Johnston, H.L.,& Carroll, D. (2000) The psychological impact of injury: effects of prior sport and exercise involvement, British Journal of Sports Medicine 34: 436-439
4. Kielhofner, G. (2008). Model of Human Occupation: Theory and Application. Fourth Edition. Philadelphia, PA: Lippincott, Williams and Wilkins
5. Mallette, P., & Ring, D. (2006) Attitudes of Hand Surgeons, Hand Surgery Patients, and the General Public Regarding Psychologic Influences on Illness, Journal of Hand Surgery, Vol 31A
6. McClay, M.H., & Levitt, E.E. (1991), The Psychological Effects of Sports Injuries, Journal of Hand Therapy, April-June
7. Moorhead, J., Cooper, C., & Moorhead, P. (2011) Personality Type and Patient Education in Hand Therapy, Journal of Hand Therapy 24: 147-154
8. Ring, D. (2011) The Role of Science and Psychology in Optimizing Care of Hand Illness, Journal of Hand Therapy, 24:82-83
9. Schindeler, P., & Stegink-Jansen, C.W. (2011) Introduction: Psychosocial Issues at Hand, Journal of Hand Therapy, 24: 80-81
10. Smith, A.M. (1996) Psychological impact of injuries in athletes, Journal of Sports Medicine, 22(6):391-40
11. Teunis, T., Thornton, E.R., Guitton, T.G., Vranceanu, A.M., & Ring, D. (2016) Coaching of patients with an isolated minimally displaced fracture of the radial head immediately increases range of motion, Journal of Hand Therapy, 29: 314-319
12. Vranceanu, A.M., & Ring, D. (2008) Value of Psychological Evaluation of the Hand Surgical Patient, Journal of Hand Surgery, 33A: 985-987
13. Vranceanu, A.M., & Ring, D. (2011) Factors Associated with Patient Satisfaction, Journal of Hand Surgery, 36A: 1504-1508
14. Vranceanu, A.M., Elbon, M., & Ring, D. (2011) The Emotive Impact of Orthopaedic Words, Journal of Hand Therapy, 24: 112-117
15. Watson, J. & Ring, D. (2008) Factors that Influence Grip Strength, Journal of Hand Surgery, 33A: 1791-1795