Patient expressions reflect disability and psychological factors. Studies of patients with back pain, cancer, and in a general medical practice note that the use of certain phrases by a patient when communicating with their healthcare provider can indicate greater disability and distress than expected for patients with a given disorder. However, it is unclear whether such phrases apply to patients with hand and arm disorders. Our study assessed whether specific patient phrases are associated with symptoms, disability, and psychological factors in patients with hand and arm disorders. 

It was found that patients who endorsed phrases in the category “I can’t” had higher scores on the Pain Catastrophizing Scale (PCS), heightened illness concern, higher arm-specific disability, and greater pain; they also had longer visits. Patients expressing “Something is wrong” had higher scores for the PCS, greater pain, and a longer visit duration. Patients using “It’s serious” had a higher score for pain. Finally, patients using “Protective mindset” had lower scores of depression and were younger in age (1). In conclusion, patient word choice may indicate underlying distress or ineffective coping strategies that represent important opportunities for empathy and support, including evidence-based cognitive and behavioral interventions.

The aim of another study was to list common phrases and feelings regarding hand surgery practice in a questionnaire and to prospectively study the correlation of these verbal expressions with possible associated feelings and disability. There was found to be a large correlation between the individual phrases and feelings questions with the Pain Self-Efficacy Questionnaire (PSEQ) and shoulder, arm, and hand disability. The best model for the combined phrases questionnaire included pain, PSEQ, smoking, and other pain conditions. The best model for the combination of all the feelings questions included PSEQ, pain, and marital status. The best model for shoulder, arm, and hand disability included phrases, PSEQ, prior treatment, and working status, with phrases being the strongest factor (2). The probability of both discrete pathophysiologies as well as the probability that addressing discrete pathophysiology will lessen symptoms and disability are both lower in patients with low self-efficacy and high illness concerns. Phrases that reflect these aspects of human illness behavior should prompt hand specialists to redouble their efforts to convey empathy, better coordinate care as one part of an interdisciplinary team led by the primary care provider, and resist the temptation to offer low-yield, potentially counterproductive tests and treatments.

Illness (symptoms and self-reported activity limitations) consistently correlates more with coping strategies and symptoms of depression than with pathophysiology or impairment. A study tested the correlation between verbal and nonverbal communication of pain (pain behavior) and upper extremity-specific disability in patients with hand and upper extremity illness. It was found that PROMIS pain behavior (verbal and nonverbal communication of pain) correlates with upper extremity disability, but PROMIS pain interference (the degree to which pain interferes with activity) is a more important factor (3). The PROMIS pain interference questionnaire could be used to identify patients with maladaptive coping strategies. This subset of patients might benefit from coaching and training on how to handle their illness.

The objective of another study was to identify demographic, injury-related, or psychological factors associated with finger stiffness at suture removal and six weeks after distal radius fracture surgery. It was found that female sex, being married, specific surgeons, carpal tunnel release, AO type C fractures, and greater catastrophic thinking were associated with increased distance to palmar crease at suture removal. At six weeks, greater catastrophic thinking was the only factor associated with increased distance to palmar crease (4). Catastrophic thinking was a consistent and major determinant of finger stiffness at suture removal and 6 weeks after injury.

A clash between a patient’s assumptions and a doctor’s advice can feel adversarial, which might influence satisfaction ratings and compliance with treatment recommendations. A better understanding of sources of patients’ bewilderment might lead to improved strategies for conveying counterintuitive information that improve patient comfort and well-being. Given the evidence that patient mindset and circumstances are associated with symptom intensity and disability and that psychological factors are associated with unexpected diagnoses, we studied the relationship of symptom intensity and magnitude of disability to patient surprise. We found that only greater symptom intensity and magnitude of self-reported activity limitations correlated with greater unexpected information when rated by the patient. There was a correlation between patient surprise and the surgeon’s perception of the patient’s surprise. Greater surgeon-perceived patient surprise correlated with nonspecific illness (5).

Prior research documents that greater psychological distress (anxiety/depression) and less effective coping strategies are associated with greater pain intensity and greater limitations, such as finger stiffness after surgery. Recognition and acknowledgment of verbal, as well as nonverbal, indicators of psychological factors might raise opportunities for improved psychological health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking. It was found that having at least one hand posture was associated with a higher degree of catastrophic thinking and kinesophobia, while greater catastrophic thinking was associated with a greater number of protective hand postures on average (6). Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery.

Our research on verbal and nonverbal signs of misconceptions is focusing on several areas:

1. We are assessing whether the improvement of coping strategies influences disability in patients with musculoskeletal illness.
2. We are assessing if treatments that ameliorate catastrophic thinking can facilitate recovery of finger motion after operative treatment of a distal radius fracture.
3. We are addressing the ability of pre-visit preparation (using decision aids or other alternative means of education) to ameliorate the discordance between patient assumptions and hand surgeon advice.

References

1. Bot AG, Vranceanu AM, Herndon JH, Ring DC. Correspondence of Patient Word Choice with Psychologic Factors in Patients With Upper Extremity Illness. Clin Orthop Relat Res. 2012 Jun 16. [Epub ahead of print] PubMed PMID: 22707072.
2. van Dijk PA, Bot AG, Neuhaus V, Mudgal CS, Ring D. The correlation of phrases and feelings with disability. Hand (N Y). 2014 Mar;9(1):67-74. doi:10.1007/s11552-013-9546-1. PubMed PMID: 24570640; PubMed Central PMCID:PMC3928385.
3. Janssen SJ, Ter Meulen DP, Nota SP, Hageman MG, Ring D. Does Verbal and Nonverbal Communication of Pain Correlate With Disability? Psychosomatics. 2014 Jun 11. pii: S0033-3182(14)00084-X. doi: 10.1016/j.psym.2014.05.009. [Epub ahead of print] PubMed PMID: 25627313.
4. Teunis T, Bot AG, Thornton ER, Ring D. Catastrophic Thinking is Associated with Finger Stiffness After Distal Radius Fracture Surgery. J Orthop Trauma. 2015 Apr 8. [Epub ahead of print] PubMed PMID: 25866942.
5. Strooker JA, Nota SP, Hageman MG, Ring DC. Patients with greater symptom intensity and more disability are more likely to be surprised by a hand surgeon’s advice. Clin Orthop Relat Res. 2015 Apr;473(4):1478-83. doi:10.1007/s11999-014-3971-5. Epub 2014 Oct 4. PubMed PMID: 25280552; PubMed Central PMCID: PMC4353519.
6.  Wilkens SC, Lans J, Bargon CA, Ring D, Chen NC. Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury. Clin Orthop Relat Res. 2018 Feb 14. doi: 10.1007/s11999.0000000000000089. [Epub ahead of print] PubMed PMID: 29480887.