Mindsets Determine Recovery of Comfort and Capability After Upper Extremity Fractures More So Than Fracture Severity

Purpose: There is increasing evidence that pathophysiology accounts for much less of the variation in symptom intensity and capability than mindsets (mental health). We used a large database of patients recovering from upper extremity fracture to determine the relative influence of mindsets and fracture severity on the recovery of magnitude of incapability and pain intensity over a 9-month trajectory.

Methods: We studied 703 patients with isolated wrist, elbow, or shoulder fractures who completed measures at baseline, 2-4 weeks, and 6-9 months after injury. Mindset measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Depression, PROMIS Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia. QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) was used to measure magnitude of incapability and numeric rating scale was used for pain intensity. Fracture severity was categorized as mild, moderate, or severe based on the AO/OTA classification. Cluster analysis was used to identify statistical groupings of measures of mindset and fracture severity. Given that fracture severity did not vary substantially between clusters, we chose to proceed without fracture severity in the statistical groupings to reduce model complexity. Conditional growth models were structured to assess the recovery trajectories of each statistical grouping for magnitude of incapability and pain intensity, accounting for fracture severity separately.

Results: We identified 4 statistical groupings with escalating levels of distress and unhelpful thoughts regarding symptoms. The conditional growth models showed that groups with higher levels of distress and unhelpful thoughts had an increasingly worse mean baseline incapability (group 2: β = 3.7, 3: β = 9.9, 4: β = 17) and pain intensity (group 3: β = 0.70, 4: β = 1.4) (P <0.01). Higher fracture severity was associated with worse baseline incapability (moderate: β = 4.5, severe: β = 6.8), and pain intensity (moderate: β = 0.37, severe: β = 0.34) (P <0.01). Groups 3 and 4 also had a slower and more prolonged rate of recovery of incapability (β = 1.3 and β = 7.0, respectively) and pain intensity (β = 0.19 and β = 1.1, respectively) (P <0.02).

Conclusion: The finding that statistical groupings with higher levels of unhelpful thoughts and feelings of distress regarding symptoms are associated with worse and prolonged recovery trajectories, independent of fracture severity and with a considerably higher effect size, reiterates the importance of anticipating and addressing mindsets during recovery from injury.

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