Psychological factors, such as symptoms of depression, health anxiety, or catastrophic thinking, are consistently associated with a magnitude of limitations and pain intensity in patients with a variety of musculoskeletal illness. Despite the abundant research on the importance of these factors in the care of both surgical and nonsurgical orthopaedic patients, including emerging evidence on the efficacy of mental health interventions in improving comfort and reducing limitations, orthopedic practices based on biopsychosocial models addressing physical, mental, and social factors are still uncommon.

Orthopedic surgeons can play a pivotal role in transitioning the care of orthopedic patients from a biomedical to a biopsychosocial model. One study found that surgeons are likely to notice and discuss psychological factors but less likely to formally screen or refer for psychological treatment (1). Transition to biopsychosocial models should focus on addressing mental health stigmas by teaching surgeons communication strategies that increase comfort discussing emotions and misconceptions. Empathic communication can help normalize less effective coping strategies and make it more appealing to develop more effective strategies.

The Gross process model of emotion regulation holds that emotion-eliciting situations (e.g. musculoskeletal illness) can be strategically regulated to determine the final emotional and behavioral response. Also, there is some evidence that innate emotional traits may predispose an individual to a particular coping style. One of our studies found that the relationships between emotion regulation strategies and physical function appear to be more dependent on the emotional response to an orthopedic condition rather than the intensity of the nociception (2). These findings support integration of emotion regulation training in skill-based psychotherapy to mitigate the negative affect and enhance the influence of positive affect on physical function.

There is little data regarding psychological interventions after acute injury. We conducted a trial comparing a workbook designed to optimize rehabilitation by improving psychological response to injury using recognized psychological techniques (the LEARN technique and goal setting) versus a workbook containing details of stretching exercises in the otherwise routine management of distal radius fracture (3). We did not measure a  benefit from the untargeted use of a psychological workbook based on the LEARN approach and goal-setting strategies in patients with distal radius fracture. Future studies can address the use of a workbook in specific situations, such as notable levels of catastrophic thinking or kinesiophobia.   

Elbow stiffness is the most common adverse event after an isolated fracture of the radial head. We assessed the effect of coaching on elbow motion during the same office visit in patients with such fractures and found that motion measures, on average, improved slightly but significantly immediately after coaching (4). 

Another study addressed the influence of questionnaire content on performance-based measurements, such as grip strength, between patients who complete the standard Pain Catastrophizing Scale (PCS) compared with patients who complete a positively adjusted PCS (5). Grip strength is a performance-based measure of upper extremity function that might be influenced by priming (the influence of a response to a stimulus by exposure to another stimulus). It was found that positive priming through a questionnaire leads to an increase in mean and maximum grip strength when compared with the standard questionnaire that uses negative terms rather than positive. 

Mindfulness based interventions may be useful for patients with musculoskeletal conditions in orthopedic surgical practices as adjuncts to medical procedures or alternatives to pain medications. However, typical mindfulness programs are lengthy and impractical in busy surgical practices. We tested the effect of a brief, 60-second mindfulness video in reducing pain and negative emotions in patients presenting to an orthopedic surgical practice. Participants showed improvements in state anxiety, pain intensity, distress, anxiety, depression and anger after watching the video (6). Overall, people with musculoskeletal pain seeking orthopedic care seem receptive and interested in brief mindfulness exercises that enhance comfort and calmness.

Our research on psychosocial interventions is focusing on several areas:

1. We are comparing different strategies for coaching patients regarding painful stretches to help clarify the optimal approach. 
2. We are investigating if there is a subgroup of patients with a negative psychological response to injury that benefits from psychological intervention and, if so, how best to identify these patients and intervene.
3. We are addressing the use of a workbook in specific situations, such as notable levels of catastrophic thinking or kinesiophobia. 

References

1. Vranceanu AM, Beks RB, Guitton TG, Janssen SJ, Ring D. How do Orthopaedic Surgeons Address Psychological Aspects of Illness? Arch Bone Jt Surg. 2017 Jan;5(1):2-9. PubMed PMID: 28271080; PubMed Central PMCID: PMC5339350.
2. Talaei-Khoei M, Nemati-Rezvani H, Fischerauer SF, Ring D, Chen N, Vranceanu AM. Emotion regulation strategies mediate the associations of positive and negative affect to upper extremity physical function. Compr Psychiatry. 2017 Mar 12;75:85-93. doi: 10.1016/j.comppsych.2017.03.005. [Epub ahead of print] PubMed PMID: 28340365.
3. Goudie S, Dixon D, McMillan G, Ring D, McQueen M. Is Use of a Psychological Workbook Associated With Improved Disabilities of the Arm, Shoulder and Hand Scores in Patients With Distal Radius Fracture? Clin Orthop Relat Res. 2018 Feb doi: 10.1007/s11999.0000000000000095. [Epub ahead of print] PubMed PMID:29406451.
4. Teunis T, Thornton ER, Guitton TG, Vranceanu AM, Ring D. Coaching of patients with an isolated minimally displaced fracture of the radial head immediately increases range of motion. J Hand Ther. 2016 Jul-Sep;29(3):314-9. doi: 10.1016/j.jht.2016.02.003. Epub 2016 Feb 18. PubMed PMID: 27496986.
5. Özkan S, Claessen FMAP, Eberlin KR, Lee SP, Ring DC, Vranceanu AM. The Effect of Priming With Questionnaire Content on Grip Strength in Patients With Hand and Upper Extremity Illness. Hand (N Y). 2017 Sep;12(5):484-489. doi: 10.1177/1558944716681975. Epub 2016 Dec 20. PubMed PMID: 28832217.
6. Chad-Friedman E, Talaei-Khoei M, Ring D, Vranceanu AM. First Use of a Brief 60-second Mindfulness Exercise in an Orthopedic Surgical Practice; Results from a Pilot Study. Arch Bone Jt Surg. 2017 Nov;5(6):400-405. PubMed PMID: 29299495.