- Email: [email protected]
Illness representations in patients with hand injury
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 927e932
Illness representations in patients with hand injury Jeffrey C.Y. Chan a,*, Joshua C.Y. Ong a, Gloria Avalos b, Padraic J. Regan a, Jack McCann a, AnnMarie Groarke c, John L. Kelly a a
Department of Plastic, Reconstructive and Hand Surgery, University College Hospital, Galway, Newcastle Road, Galway, Ireland b Department of Medical Informatics and Medical Education, National University of Ireland, Galway, University Road, Galway, Ireland c Department of Psychology, National University of Ireland, Galway, University Road, Galway, Ireland Received 26 May 2007; accepted 4 November 2007
KEYWORDS Disability; Hand injury; Illness belief; Illness perception; Severity
Summary Purpose: Differences in illness perception about hand injury may partly explain the variation in health behaviours such as adherence to post-operative therapy, coping strategy, emotional response and eventual clinical outcome. This study examined the illness perception of patients with hand injuries in the acute trauma setting. Methods: The disability and severity of injury were assessed using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Hand Injury Severity Score (HISS). The revised Illness Perception Questionnaire (IPQ-R) was used to explore patients’ illness beliefs and perception on hand injury. Results: Fifty seven patients were recruited over the 2 month period. The IPQ-R showed good internal reliability (Cronbach’s alpha, 0.68e0.86). There was no correlation between the DASH or HISS scores and the various components of the IPQ-R scores, suggesting that illness perceptions were not influenced by the recent trauma experience. Patients with dominant hand injuries and females reported significantly higher subjective disability. Younger patients believed their injury would last for a limited duration but reported a significantly higher number of related symptoms. Overall, the cohort was optimistic about their treatment and duration of recovery (high treatment control score and low time line score). Beliefs of negative consequences, chronic/cyclical duration and low illness coherence were linked with negative emotional response. High illness identity was associated with perception of pessimistic outcome (high consequences score) and negative emotional response. Conclusions: The lack of correlations suggests that illness perceptions of patients do not necessarily relate to the recent trauma experience or the severity of their hand injury.
* Corresponding author. National Centre for Biomedical Engineering Science, National University of Ireland Galway, Galway, Ireland. Tel.: þ353 87 6393718; fax: þ353 91 544915. E-mail address: [email protected] (J.C.Y. Chan). 1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.11.057
928
J.C.Y. Chan et al. Patients in this cohort were optimistic about treatment and their recovery. There was some evidence to suggest that patients with severe injury were over-optimistic about recovery. These findings suggest that there could be a role for psychological intervention in hand injury. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Hand injuries represent one of the most common injuries to the body. They comprise between 6.6% and 28.6% of all injuries1e3 and have the potential to cause long term physical and functional disability.4 The onset of a potentially disabling condition such as hand injury brings with it a range of difficulties. These difficulties may show considerable variation in their nature, severity, course and outcome as perceived by the patient. Patients’ beliefs and perceptions of an illness or health threat can play a role in determining their health behaviour.5e7 The difference in beliefs and perceptions of individual patients may partly explain the variation in their compliance to treatment or rehabilitation, their emotional adjustment and their eventual outcome after the injury. Treatment and recovery from hand injury is not a passive process that relies solely on the technical capability of the operating hand surgeon. The injured patient needs to participate in a post-operative therapy programme where its success is dependent on the individual patient’s participation, compliance and adherence. It had been shown that a patient’s own expectations about their recovery can predict their eventual outcome, even after controlling for other clinical prognostic factors. In one study, patients with a positive expectation spent less time off work and received worker’s compensation benefit for a shorter duration.8 Surgeons who sustained hand injuries have been shown to return to their operative duties ahead of schedule.9 This may partly be due to their accurate understanding of their injury, perceived ability to adapt to the injury and their positive motivation to return to work. Recently, there have been interests in understanding how patients’ beliefs and ideas of their illness are associated with their adjustment to illness.10 According to Leventhal’s self-regulatory model, when patients are diagnosed with a condition, they make sense of this health threat by developing their own organised beliefs and ideas (cognitive representations) which influence how the person would respond to the health threat.11,12 As the patient gains information about their condition, they integrate them into their existing knowledge structure. Such a structure is based upon information received from previous sources which may include their family, friends, clinician, the media and existing cultural notions. If the new information does not fit into what the patient already believes, this information is often altered to fit their existing beliefs. This can lead to distorted conclusions concerning their condition which can influence emotional response (e.g. anxiety) and coping behaviour (e.g. adherence to therapy), possibly leading to poor clinical outcome.13 Changing these beliefs with simple intervention (such as counselling) may enhance emotional adjustment and adherence to therapy. Early interventions aimed at changing misconceptions, challenging negative beliefs and exploring concerns led to positive
changes in the patients’ views about their condition, earlier return to work and lower incidence of symptoms in a randomised study.5 To our knowledge, the perceptions of patients with hand injury have not been studied. Patients who have unrealistic or negative perceptions about their hand injury may benefit from a brief intervention such as counselling. As the first step towards this goal, we set out to objectively examine the perception of patients who had sustained a hand injury and who were referred to the Department of Plastic, Reconstructive and Hand Surgery. Using the validated revised version of the Illness Perception Questionnaire (IPQ-R)14,15, we explored the nature and interrelationships between illness perceptions and clinical severity of patients with hand injuries in the acute setting.
Materials and methods Study design and patient population A study was carried out over a 2 month period in a tertiary referral University Teaching Hospital. Consecutive patients with acute hand injury which required surgery were recruited. The patients were admitted under the care of one of the three consultants in plastic and hand surgery in our unit. Patients were requested to complete the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the revised Illness Perception Questionnaire (IPQ-R) at the time of admission from the accident and emergency department. When this was not possible due to practical reasons, the questionnaires were completed on the ward. Informed consent was obtained from the patients. It was explained that the study was purely observational and that their responses would be confidential and would not affect the management of their injury in any way.
Assessment of hand injury disability and severity The DASH questionnaire is a validated 30-item, self-report questionnaire designed to measure physical function and symptoms in patients with one or several musculoskeletal disorders of the upper limb.16,17 The DASH score is a selfreport measure of symptoms and function. The questionnaire describes the disability related to upper limb disorders from the patient’s perspective and it also monitors changes in symptoms and function over time.18 The DASH has been shown to correlate with health status, injury severity and function.18e20 The objective severity of the hand injury was determined retrospectively from the medical notes by calculating the Hand Injury Severity Score (HISS).21 This objective anatomical assessment scores the injuries
Illness representations in hand injury depending on the degree of damage in the categories: integument, skeletal, motor and neural for each individual digit. The total score for each digit is then multiplied by a weighting factor for that digit and the total for all the rays then gives the final score. The HISS score has been shown to be associated with time off work, function and impairment.20,22e24
Measure of illness perception The IPQ-R questionnaire is a quantitative measure developed to assess the different components of the cognitive and emotional representations of illness.14 The patient’s beliefs or ideas about an illness are formed around these components: (1) Identity (the label the patient uses to describe the illness or diagnosis, and the number of symptoms the patient views as being part of the illness), (2) Timeline (the duration the patient believes the illness will last - acute, chronic or cyclical), (3) Consequences (the expected effects and outcome of the condition on physical, social and psychological well-being), (4) Personal and Treatment Control (the extent to which the patients believe their illness can be controlled or cured through treatment or behaviours), (5) Illness Coherence (the extent to which the illness representation makes sense to the patient), (6) Emotional Representation (affective responses associated with their condition such as anxiety or depression), and (7) Causes (personal ideas about the cause of the illness). The IPQ-R has three parts and the ‘injury version’ of the IPQ-R was used in this study. The first part of the questionnaire measures the illness identity. A list of 14 common symptoms is given (e.g. pain, nausea, fatigue, stiff joint, loss of strength, sleep difficulties etc.) and the patient is asked to rate whether he/she has experience of each symptom since their injury, and if he/she believes the symptom is related to the injury (yes/no). The total number of yes-rated symptoms forms the identity score. Higher scores represent a strongly held belief about the number of symptoms attributed to the injury. The second part of the questionnaire consists of 38 statements using a 5-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree and strongly agree). Answers from this section provide scores for the timeline, consequences, control (personal control and treatment control), illness coherence and emotional representation components of the IPQ-R. There are two timeline components measured: acute-chronic timeline and cyclical timeline. Higher scores on the scales indicate strong beliefs in chronic nature and/or cyclical nature of the injury, serious consequences of the injury, the patient’s own ability to control the condition and the effectiveness of treatment. Higher scores on illness coherence indicate the patient’s ability to understand or make sense of the condition, while higher scores on the emotional representation component indicate a stronger negative emotional response to the injury.
929 The final part of the questionnaire enquires about the patient’s personal opinion on the possible causes (18 items) of the injury (e.g. stress, bad luck, own behaviour, overwork, mental attitude, alcohol, accident etc.) using the same 5-point Likert scale. The causes commonly attributed (>10%) by the patients were included for further analysis. Statistical analysis The data were entered into a Microsoft Excel (Microsoft Corporation) spreadsheet and analysed using SPSS 14.0.1 for Windows (LEAD Technologies, Inc). The mean scores were calculated for each of the components of the IPQ-R (with some items reverse coded) to allow comparison. The scores obtained from the DASH, HISS and IPQ-R were analysed with Pearson’s Product Moment Correlation tests to evaluate the relationships between the parameters. Independent t-tests were used to analyse the differences between two independent groups (e.g. hand dominance, gender). A p value of <0.05 was considered to be statistically significant. Cronbach’s alpha was determined to assess the internal reliability of each component of the IPQ-R for our cohort of patients.
Results Patient demographics Fifty seven patients were recruited over the 2 month period. The mean age of the cohort was 38.2 years (SD Z 17.2, range 15e76). Fifty nine percent of injuries involved the dominant hand. There were 12 female and 45 male patients (Table 1). There was no significant difference in patients’ age between gender and the injured side (dominant/non-dominant). The number of patients may seem Table 1 Patients characteristics including age, gender, hand dominance, DASH and HISS scores Characteristics
Results
Age (range) Mean SD Median
15e76 38.2 17.2 34
Gender (No. of patients) Male (%) Female (%)
57 45 (78.9%) 12 (21.1%)
Dominant Hand Injury (%) Non-dominant Hand Injury (%)
34 (59.6%) 23 (40.4%)
DASH Score Mean SD Median Range
41.2 27.2 42.6 0e98
HISS Score Mean (SD) Range Grade I e minor (20) Grade II e moderate (21e50) Grade III e severe (51e100) Grade IV e major (>100)
28.0 27.1 6e153 33 17 5 2
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J.C.Y. Chan et al.
relatively small for a regional referral unit. However, only injuries exclusively involving the hand (distal to the wrist) were included. Bilateral hand injuries or hand injuries involving another site such as the forearm were excluded in an attempt to standardise the cohort.
Perceptions of hand injury The IPQ-R showed good and acceptable internal reliability in our cohort (Table 2). The Cronbach’s alpha values for the components ranged from 0.68 (personal control component) to 0.86 (acute-chronic timeline component). Overall, the patients in this cohort reported a minimal number of symptoms (mean Z 2.35, median Z 2) experienced in relation to their injury. Common symptoms recognised by patients as part of their injury were pain (91.2%), sleep difficulties (31.6%), loss of strength (29.8%), sore joints (21.1%) and fatigue (19.3%). Table 2 shows the mean IPQ-R component scores for the cohort. Higher treatment control score compared to personal control score suggests that the majority believed that clinical treatment is the main means of managing their injury. Reassuringly, most patients believed that they have a personal understanding of their condition, as indicated by the high illness coherence score. A low timeline score and modest consequences score demonstrate that the majority were optimistic about a short duration of illness and full recovery from their injury. However, this observation should be interpreted with caution as the majority of patients had minor injury (HISS Grade I). Nevertheless, when we analysed the small number of patients with HISS Grade III or higher, we found that this subset were even more optimistic about recovery (lower timeline score) and did not attribute any worse consequences to their injury. The modest emotional representation score suggests that most patients in this study would not respond negatively to their injury. The cohort identified four main causes of their injury. They were accident (71.9%), chance or bad luck (56.1%), patients own behaviour (33.3%) and overwork (10.5%). Those who attributed their injury to an accident subjectively had a lower DASH score (p < 0.05). Injuries that were perceived
Table 2 IPQ-R components mean (SD) scores and internal reliability (Cronbach’s alpha) Perceptions of patients with hand injury showing components of the Revised-Illness Perception Questionnaire (IPQ-R) and internal reliability of the patient cohort (Cronbach’s Alpha)
Identity Timeline (Acute/Chronic) Consequences Personal Control Treatment Control Illness Coherence Timeline (Cyclical) Emotional Representation
Mean SD
Cronbach’s Alpha
2.35 2.02 2.22 0.89 2.51 0.83 3.51 0.70 3.96 0.71 3.96 0.67 2.14 0.81 2.46 0.95
0.76 0.86 0.81 0.68 0.73 0.69 0.80 0.84
to be due to luck (p < 0.05) or patients own behaviour (p < 0.05) were less severe as measured with HISS.
Correlational analyses There was no correlation between the subjective DASH score and the objective HISS score (Table 3). This finding has been reported previously.23 Interestingly, there was also no correlation between DASH/HISS scores and all the components of the illness perceptions scores. Thus, neither the objective severity nor subjective disability necessarily influenced the patients’ beliefs about the symptoms, course or outcome of their injury. There was a positive correlation between timeline scores (chronic/cyclical) and consequences score. This indicates that a perception of more serious consequences was associated with beliefs that the injury would have a chronic/cyclical outcome. Those who perceived negative consequences to the injury, a chronic/cyclical duration, and low illness coherence were more likely to report a negative emotional response. In addition, those who attributed more symptoms to their injury had more beliefs of pessimistic outcome (high consequences score) and were more likely to have a negative emotional response. As expected, positive beliefs about treatment control and personal control were associated with the belief of acute illness duration. Greater perceived understanding of the injury (coherence) was linked with the belief that treatment would be helpful. The overall low timeline and modest consequences scores, and high treatment and personal control scores, would imply that this cohort might be over-optimistic about their treatment and recovery. Interestingly, we found no relationship between treatment control and consequences scores as a clinician would generally expect. There was no obvious explanation for this observation.
Age, gender, hand dominance and illness perceptions Younger patients reported more symptoms related to the injury (higher identity score) (r Z 0.294, p < 0.05). There was a positive correlation between age and timeline score, indicating that younger patients believed their condition would last a limited duration (r Z þ0.269, p < 0.05). Those with injuries to the dominant hand (t Z 2.648, p Z 0.01) and female patients (t Z 2.833, p Z 0.006) had a significantly higher DASH score, but showed no difference in the HISS score. Patients with injuries to the dominant hand also attributed more symptoms related to their injuries (t Z 3.390, p Z 0.001), believed that their symptoms would come and go in cycles (t Z 2.052, p Z 0.045) and were less able to understand or make sense of their condition (lower illness coherence score, t Z 2.061, p Z 0.044).
Discussion Overall, the cohort was optimistic about their treatment and duration of recovery (high treatment control score and low timeline). Beliefs of negative consequences, chronic/ cyclical duration and low illness coherence were linked
Illness representations in hand injury Table 3
931
Intercorrelations between DASH, HISS and IPQ-R scores DASH
HISS
Identity Timeline (Acute/ Chronic)
Consequences Personal control
HISS 0.131 Identity 0.228 0.119 Timeline (Acute/Chronic) 0.237 0.068 0.025 Consequences 0.211 0.164 0.266* 0.532*** Personal Control 0.042 0.007 0.027 0.278* 0.033 Treatment Control 0.057 0.014 0.132 0.542*** 0.207 Illness Coherence 0.126 0.104 0.044 0.262 0.169 Timeline (Cyclical) 0.126 0.126 0.054 0.461*** 0.553*** Emotional Representation 0.186 0.011 0.296* 0.273* 0.519***
Treatment Illness Timeline control coherence (Cyclical)
0.503*** 0.040 0.285* 0.127 0.336* 0.048 0.165
0.436** 0.279*
0.545***
*** p < 0.001. ** p < 0.01. * p < 0.05.
with negative emotional response. High illness identity was associated with perception of pessimistic outcome (high consequences score) and negative emotional response. Research has examined the way in which patients cope with various illnesses. Patients can vary widely in their perceptions and subsequently, the manner in which they respond and adapt to health threats.6,25e27 In this study, we examined the illness beliefs in a cohort of patients with hand injury. It is undeniable that hand trauma can result in considerable burden and place stress on the health, social, economic and psychological well-being of the patient.4,28 Exploring the perceptions of patients may help us to manage any negative illness beliefs and provide a strategy for coping and adjustment.7 One interesting finding in this study was that neither the HISS nor the DASH score correlates with any of the illness perception components. This suggests that the patients might have pre-formed beliefs about the course and outlook of hand injury, and the injury which they sustained did not necessarily alter these existing (fixed) beliefs. In fact, we found that the majority were very optimistic and perceived that their injury would last for a limited time and be without severe consequences. These unrealistic beliefs must be altered because such inflated expectation could only lead to a mismatch in expectation, leading to disappointment, negative coping behaviour and negative emotional response.26,29e31 In this study, we found that the small subset with severe injury (HISS Grade III or higher) were more optimistic about recovery than the rest of the cohort. Further research is needed in patients with severe injury, as they could be the potential target for psychological intervention to overcome their unrealistic beliefs. It is noteworthy that our study found that illness identity was linked to beliefs of serious consequences and negative emotional response. Although interpretation of this finding was limited by the cross-sectional nature of the study, we suggest that lessening symptoms during the pre- and postoperative period might alter these pessimistic beliefs. As over 90% of our patients experienced pain in the acute setting, reducing pain (e.g. generous analgesia and fracture splinting) might help to alter these negative beliefs. Only a prospective longitudinal study assessing the adequacy of symptom control would clarify this. It is not known why
a large number of patients attributed sleep difficulties as part of their illness identity. We suspect that patients might have interpreted their anxiety about their surgery as a cause of sleep difficulties. It is likely that patients’ behaviour and coping strategy would change throughout the recovery period. We suspect pre-injury perceptions would influence this to a certain extent. In this study, we evaluated illness beliefs in the acute trauma setting. However, it is imperative that future research examines whether these beliefs would change after surgery and a period of recovery. The post-operative period is crucial as rehabilitation with hand therapy relies on patient compliance. Negative coping behaviour and pessimistic beliefs about the benefit of therapy during this period would lead to poor adherence and a less optimal outcome. Despite the limitation of the present study, it provides information on the nature of illness representations in this patient group and provides a foundation for further longitudinal research in the hand trauma setting. In summary, there was no correlation between the various components of illness beliefs and subjective or objective severity, suggesting that patients’ perceptions were not influenced by the recent trauma experience. Patients in this cohort were optimistic about what treatment could offer and their subsequent recovery. There was some evidence to suggest that patients with severe injury were over-optimistic and these findings suggest that there could be a role for psychological intervention (e.g. counselling) to modify any unrealistic expectations and negative emotional response in order to improve compliance to treatment and rehabilitation. In conclusion, the illness beliefs that patients hold in relation to their hand injuries do not necessarily relate to the severity of the injury. Further research is needed to evaluate and understand the role of illness perception in hand injury, especially during the post-operative recovery period.
References 1. Packer GJ, Shaheen MA. Patterns of hand fractures and dislocations in a district general hospital. J Hand Surg [Br] 1993;18: 511e4.
932 2. Angermann P, Lohmann M. Injuries to the hand and wrist. A study of 50,272 injuries. J Hand Surg [Br] 1993;18:642e4. 3. Hill C, Riaz M, Mozzam A, et al. A regional audit of hand and wrist injuries. A study of 4873 injuries. J Hand Surg [Br] 1998;23:196e200. 4. Trybus M, Lorkowski J, Brongel L, et al. Causes and consequences of hand injuries. Am J Surg 2006;192:52e7. 5. Petrie KJ, Cameron LD, Ellis CJ, et al. Changing illness perceptions after myocardial infarction: an early intervention randomized controlled trial. Psychosom Med 2002;64:580e6. 6. Petrie KJ, Weinman J, Sharpe N, et al. Role of patients’ view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study. BMJ 1996;312: 1191e4. 7. Groarke A, Curtis R, Coughlan R, et al. The role of perceived and actual disease status in adjustment to rheumatoid arthritis. Rheumatology (Oxford) 2004;43:1142e9. 8. Cole DC, Mondloch MV, Hogg-Johnson S. Listening to injured workers: how recovery expectations predict outcomesea prospective study. CMAJ 2002;166:749e54. 9. Chin KR, Lonner JH, Jupiter BS, et al. The surgeon as a hand patient: the clinical and psychological impact of hand and wrist fractures. J Hand Surg [Am] 1999;24:59e63. 10. Murray M. Lay representation of illness. In: Bennett P, editor. Current developments in health psychology. London: Harwood Academic Publishers; 1990. p. 63e92. 11. Leventhal H. The active side of illness cognition. In: Skelton JA, editor. Mental representation in health and illness. New York: Springer-Verlag; 1991. p. 247e68. 12. Petrie KJ. Health-related cognitions. In: Sutton S, editor. The SAGE handbook of health psychology. London: SAGE Publications Ltd.; 2003. p. 127e42. 13. Groth GN, Wilder DM, Young VL. The impact of compliance on the rehabilitation of patients with mallet finger injuries. J Hand Ther 1994;7:21e4. 14. Weinman J, Petrie KJ, Moss-Morris R, et al. The Illness Perception Questionnaire: A new method for assessing the cognitive representation of illness. Psychol Health 1996;11:431e45. 15. Moss-Morris R, Weinman J, Petrie KJ, et al. The Revised Illness Perception Questionnaire (IPQ-R). Psychol Health 2002;17: 1e16. 16. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602e8.
J.C.Y. Chan et al. 17. The DASH outcome measure. Available at: http://www.dash. iwh.on.ca/ 18. Jester A, Harth A, Wind G, et al. Disabilities of the arm, shoulder and hand (DASH) questionnaire: determining functional activity profiles in patients with upper extremity disorders. J Hand Surg [Br] 2005;30:23e8. 19. SooHoo NF, McDonald AP, Seiler Iii JG, et al. Evaluation of the construct validity of the DASH questionnaire by correlation to the SF-36. J Hand Surg [Am] 2002;27:537e41. 20. Saxena P, Cutler L, Feldberg L. Assessment of the severity of hand injuries using ‘hand injury severity score’, and its correlation with the functional outcome. Injury 2004;35:511e6. 21. Campbell DA, Kay SP. The hand injury severity scoring system. J Hand Surg [Br] 1996;21:295e8. 22. Van Der Molen AB, Matloub HS, Dzwierzynski W, et al. The hand injury severity scoring system and workers’ compensation cases in Wisconsin, USA. J Hand Surg [Br] 1999;24:184e6. 23. Mink van der Molen AB, Ettema AM, Hovius SER. Outcome of hand trauma: the hand injury severity scoring system (HISS) and subsequent impairment and disability. J Hand Surg [Br] 2003;28:295e9. 24. Watts AM, Greenstock M, Cole RP. Outcome following the rehabilitation of hand trauma patients: The importance of a subjective functional assessment. J Hand Surg [Br] 1998; 23:485e9. 25. Edwards R, Suresh R, Lynch S, et al. Illness perceptions and mood in chronic fatigue syndrome. J Psychosom Res 2001;50: 65e8. 26. Goldstein LH, Holland L, Soteriou H, et al. Illness representations, coping styles and mood in adults with epilepsy. Epilepsy Res 2005;67:1e11. 27. Covic A, Seica A, Gusbeth-Tatomir P, et al. Illness representations and quality of life scores in haemodialysis patients. Nephrol Dial Transplant 2004;19:2078e83. 28. Dias JJ, Garcia-Elias M. Hand injury costs. Injury 2006;37: 1071e7. 29. Jopson NM, Moss-Morris R. The role of illness severity and illness representations in adjusting to multiple sclerosis. J Psychosom Res 2003;54:503e11. 30. Schiaffino KM, Shawaryn MA, Blum D. Examining the impact of illness representations on psychological adjustment to chronic illnesses. Health Psychol 1998;17:262e8. 31. Vaughan R, Morrison L, Miller E. The illness representations of multiple sclerosis and their relations to outcome. Br J Health Psychol 2003;8:287e301.
Illness representations in patients with hand injury Jeffrey C.Y. Chan a,*, Joshua C.Y. Ong a, Gloria Avalos b, Padraic J. Regan a, Jack McCann a, AnnMarie Groarke c, John L. Kelly a a
Department of Plastic, Reconstructive and Hand Surgery, University College Hospital, Galway, Newcastle Road, Galway, Ireland b Department of Medical Informatics and Medical Education, National University of Ireland, Galway, University Road, Galway, Ireland c Department of Psychology, National University of Ireland, Galway, University Road, Galway, Ireland Received 26 May 2007; accepted 4 November 2007
KEYWORDS Disability; Hand injury; Illness belief; Illness perception; Severity
Summary Purpose: Differences in illness perception about hand injury may partly explain the variation in health behaviours such as adherence to post-operative therapy, coping strategy, emotional response and eventual clinical outcome. This study examined the illness perception of patients with hand injuries in the acute trauma setting. Methods: The disability and severity of injury were assessed using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Hand Injury Severity Score (HISS). The revised Illness Perception Questionnaire (IPQ-R) was used to explore patients’ illness beliefs and perception on hand injury. Results: Fifty seven patients were recruited over the 2 month period. The IPQ-R showed good internal reliability (Cronbach’s alpha, 0.68e0.86). There was no correlation between the DASH or HISS scores and the various components of the IPQ-R scores, suggesting that illness perceptions were not influenced by the recent trauma experience. Patients with dominant hand injuries and females reported significantly higher subjective disability. Younger patients believed their injury would last for a limited duration but reported a significantly higher number of related symptoms. Overall, the cohort was optimistic about their treatment and duration of recovery (high treatment control score and low time line score). Beliefs of negative consequences, chronic/cyclical duration and low illness coherence were linked with negative emotional response. High illness identity was associated with perception of pessimistic outcome (high consequences score) and negative emotional response. Conclusions: The lack of correlations suggests that illness perceptions of patients do not necessarily relate to the recent trauma experience or the severity of their hand injury.
* Corresponding author. National Centre for Biomedical Engineering Science, National University of Ireland Galway, Galway, Ireland. Tel.: þ353 87 6393718; fax: þ353 91 544915. E-mail address: [email protected] (J.C.Y. Chan). 1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.11.057
928
J.C.Y. Chan et al. Patients in this cohort were optimistic about treatment and their recovery. There was some evidence to suggest that patients with severe injury were over-optimistic about recovery. These findings suggest that there could be a role for psychological intervention in hand injury. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Hand injuries represent one of the most common injuries to the body. They comprise between 6.6% and 28.6% of all injuries1e3 and have the potential to cause long term physical and functional disability.4 The onset of a potentially disabling condition such as hand injury brings with it a range of difficulties. These difficulties may show considerable variation in their nature, severity, course and outcome as perceived by the patient. Patients’ beliefs and perceptions of an illness or health threat can play a role in determining their health behaviour.5e7 The difference in beliefs and perceptions of individual patients may partly explain the variation in their compliance to treatment or rehabilitation, their emotional adjustment and their eventual outcome after the injury. Treatment and recovery from hand injury is not a passive process that relies solely on the technical capability of the operating hand surgeon. The injured patient needs to participate in a post-operative therapy programme where its success is dependent on the individual patient’s participation, compliance and adherence. It had been shown that a patient’s own expectations about their recovery can predict their eventual outcome, even after controlling for other clinical prognostic factors. In one study, patients with a positive expectation spent less time off work and received worker’s compensation benefit for a shorter duration.8 Surgeons who sustained hand injuries have been shown to return to their operative duties ahead of schedule.9 This may partly be due to their accurate understanding of their injury, perceived ability to adapt to the injury and their positive motivation to return to work. Recently, there have been interests in understanding how patients’ beliefs and ideas of their illness are associated with their adjustment to illness.10 According to Leventhal’s self-regulatory model, when patients are diagnosed with a condition, they make sense of this health threat by developing their own organised beliefs and ideas (cognitive representations) which influence how the person would respond to the health threat.11,12 As the patient gains information about their condition, they integrate them into their existing knowledge structure. Such a structure is based upon information received from previous sources which may include their family, friends, clinician, the media and existing cultural notions. If the new information does not fit into what the patient already believes, this information is often altered to fit their existing beliefs. This can lead to distorted conclusions concerning their condition which can influence emotional response (e.g. anxiety) and coping behaviour (e.g. adherence to therapy), possibly leading to poor clinical outcome.13 Changing these beliefs with simple intervention (such as counselling) may enhance emotional adjustment and adherence to therapy. Early interventions aimed at changing misconceptions, challenging negative beliefs and exploring concerns led to positive
changes in the patients’ views about their condition, earlier return to work and lower incidence of symptoms in a randomised study.5 To our knowledge, the perceptions of patients with hand injury have not been studied. Patients who have unrealistic or negative perceptions about their hand injury may benefit from a brief intervention such as counselling. As the first step towards this goal, we set out to objectively examine the perception of patients who had sustained a hand injury and who were referred to the Department of Plastic, Reconstructive and Hand Surgery. Using the validated revised version of the Illness Perception Questionnaire (IPQ-R)14,15, we explored the nature and interrelationships between illness perceptions and clinical severity of patients with hand injuries in the acute setting.
Materials and methods Study design and patient population A study was carried out over a 2 month period in a tertiary referral University Teaching Hospital. Consecutive patients with acute hand injury which required surgery were recruited. The patients were admitted under the care of one of the three consultants in plastic and hand surgery in our unit. Patients were requested to complete the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the revised Illness Perception Questionnaire (IPQ-R) at the time of admission from the accident and emergency department. When this was not possible due to practical reasons, the questionnaires were completed on the ward. Informed consent was obtained from the patients. It was explained that the study was purely observational and that their responses would be confidential and would not affect the management of their injury in any way.
Assessment of hand injury disability and severity The DASH questionnaire is a validated 30-item, self-report questionnaire designed to measure physical function and symptoms in patients with one or several musculoskeletal disorders of the upper limb.16,17 The DASH score is a selfreport measure of symptoms and function. The questionnaire describes the disability related to upper limb disorders from the patient’s perspective and it also monitors changes in symptoms and function over time.18 The DASH has been shown to correlate with health status, injury severity and function.18e20 The objective severity of the hand injury was determined retrospectively from the medical notes by calculating the Hand Injury Severity Score (HISS).21 This objective anatomical assessment scores the injuries
Illness representations in hand injury depending on the degree of damage in the categories: integument, skeletal, motor and neural for each individual digit. The total score for each digit is then multiplied by a weighting factor for that digit and the total for all the rays then gives the final score. The HISS score has been shown to be associated with time off work, function and impairment.20,22e24
Measure of illness perception The IPQ-R questionnaire is a quantitative measure developed to assess the different components of the cognitive and emotional representations of illness.14 The patient’s beliefs or ideas about an illness are formed around these components: (1) Identity (the label the patient uses to describe the illness or diagnosis, and the number of symptoms the patient views as being part of the illness), (2) Timeline (the duration the patient believes the illness will last - acute, chronic or cyclical), (3) Consequences (the expected effects and outcome of the condition on physical, social and psychological well-being), (4) Personal and Treatment Control (the extent to which the patients believe their illness can be controlled or cured through treatment or behaviours), (5) Illness Coherence (the extent to which the illness representation makes sense to the patient), (6) Emotional Representation (affective responses associated with their condition such as anxiety or depression), and (7) Causes (personal ideas about the cause of the illness). The IPQ-R has three parts and the ‘injury version’ of the IPQ-R was used in this study. The first part of the questionnaire measures the illness identity. A list of 14 common symptoms is given (e.g. pain, nausea, fatigue, stiff joint, loss of strength, sleep difficulties etc.) and the patient is asked to rate whether he/she has experience of each symptom since their injury, and if he/she believes the symptom is related to the injury (yes/no). The total number of yes-rated symptoms forms the identity score. Higher scores represent a strongly held belief about the number of symptoms attributed to the injury. The second part of the questionnaire consists of 38 statements using a 5-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree and strongly agree). Answers from this section provide scores for the timeline, consequences, control (personal control and treatment control), illness coherence and emotional representation components of the IPQ-R. There are two timeline components measured: acute-chronic timeline and cyclical timeline. Higher scores on the scales indicate strong beliefs in chronic nature and/or cyclical nature of the injury, serious consequences of the injury, the patient’s own ability to control the condition and the effectiveness of treatment. Higher scores on illness coherence indicate the patient’s ability to understand or make sense of the condition, while higher scores on the emotional representation component indicate a stronger negative emotional response to the injury.
929 The final part of the questionnaire enquires about the patient’s personal opinion on the possible causes (18 items) of the injury (e.g. stress, bad luck, own behaviour, overwork, mental attitude, alcohol, accident etc.) using the same 5-point Likert scale. The causes commonly attributed (>10%) by the patients were included for further analysis. Statistical analysis The data were entered into a Microsoft Excel (Microsoft Corporation) spreadsheet and analysed using SPSS 14.0.1 for Windows (LEAD Technologies, Inc). The mean scores were calculated for each of the components of the IPQ-R (with some items reverse coded) to allow comparison. The scores obtained from the DASH, HISS and IPQ-R were analysed with Pearson’s Product Moment Correlation tests to evaluate the relationships between the parameters. Independent t-tests were used to analyse the differences between two independent groups (e.g. hand dominance, gender). A p value of <0.05 was considered to be statistically significant. Cronbach’s alpha was determined to assess the internal reliability of each component of the IPQ-R for our cohort of patients.
Results Patient demographics Fifty seven patients were recruited over the 2 month period. The mean age of the cohort was 38.2 years (SD Z 17.2, range 15e76). Fifty nine percent of injuries involved the dominant hand. There were 12 female and 45 male patients (Table 1). There was no significant difference in patients’ age between gender and the injured side (dominant/non-dominant). The number of patients may seem Table 1 Patients characteristics including age, gender, hand dominance, DASH and HISS scores Characteristics
Results
Age (range) Mean SD Median
15e76 38.2 17.2 34
Gender (No. of patients) Male (%) Female (%)
57 45 (78.9%) 12 (21.1%)
Dominant Hand Injury (%) Non-dominant Hand Injury (%)
34 (59.6%) 23 (40.4%)
DASH Score Mean SD Median Range
41.2 27.2 42.6 0e98
HISS Score Mean (SD) Range Grade I e minor (20) Grade II e moderate (21e50) Grade III e severe (51e100) Grade IV e major (>100)
28.0 27.1 6e153 33 17 5 2
930
J.C.Y. Chan et al.
relatively small for a regional referral unit. However, only injuries exclusively involving the hand (distal to the wrist) were included. Bilateral hand injuries or hand injuries involving another site such as the forearm were excluded in an attempt to standardise the cohort.
Perceptions of hand injury The IPQ-R showed good and acceptable internal reliability in our cohort (Table 2). The Cronbach’s alpha values for the components ranged from 0.68 (personal control component) to 0.86 (acute-chronic timeline component). Overall, the patients in this cohort reported a minimal number of symptoms (mean Z 2.35, median Z 2) experienced in relation to their injury. Common symptoms recognised by patients as part of their injury were pain (91.2%), sleep difficulties (31.6%), loss of strength (29.8%), sore joints (21.1%) and fatigue (19.3%). Table 2 shows the mean IPQ-R component scores for the cohort. Higher treatment control score compared to personal control score suggests that the majority believed that clinical treatment is the main means of managing their injury. Reassuringly, most patients believed that they have a personal understanding of their condition, as indicated by the high illness coherence score. A low timeline score and modest consequences score demonstrate that the majority were optimistic about a short duration of illness and full recovery from their injury. However, this observation should be interpreted with caution as the majority of patients had minor injury (HISS Grade I). Nevertheless, when we analysed the small number of patients with HISS Grade III or higher, we found that this subset were even more optimistic about recovery (lower timeline score) and did not attribute any worse consequences to their injury. The modest emotional representation score suggests that most patients in this study would not respond negatively to their injury. The cohort identified four main causes of their injury. They were accident (71.9%), chance or bad luck (56.1%), patients own behaviour (33.3%) and overwork (10.5%). Those who attributed their injury to an accident subjectively had a lower DASH score (p < 0.05). Injuries that were perceived
Table 2 IPQ-R components mean (SD) scores and internal reliability (Cronbach’s alpha) Perceptions of patients with hand injury showing components of the Revised-Illness Perception Questionnaire (IPQ-R) and internal reliability of the patient cohort (Cronbach’s Alpha)
Identity Timeline (Acute/Chronic) Consequences Personal Control Treatment Control Illness Coherence Timeline (Cyclical) Emotional Representation
Mean SD
Cronbach’s Alpha
2.35 2.02 2.22 0.89 2.51 0.83 3.51 0.70 3.96 0.71 3.96 0.67 2.14 0.81 2.46 0.95
0.76 0.86 0.81 0.68 0.73 0.69 0.80 0.84
to be due to luck (p < 0.05) or patients own behaviour (p < 0.05) were less severe as measured with HISS.
Correlational analyses There was no correlation between the subjective DASH score and the objective HISS score (Table 3). This finding has been reported previously.23 Interestingly, there was also no correlation between DASH/HISS scores and all the components of the illness perceptions scores. Thus, neither the objective severity nor subjective disability necessarily influenced the patients’ beliefs about the symptoms, course or outcome of their injury. There was a positive correlation between timeline scores (chronic/cyclical) and consequences score. This indicates that a perception of more serious consequences was associated with beliefs that the injury would have a chronic/cyclical outcome. Those who perceived negative consequences to the injury, a chronic/cyclical duration, and low illness coherence were more likely to report a negative emotional response. In addition, those who attributed more symptoms to their injury had more beliefs of pessimistic outcome (high consequences score) and were more likely to have a negative emotional response. As expected, positive beliefs about treatment control and personal control were associated with the belief of acute illness duration. Greater perceived understanding of the injury (coherence) was linked with the belief that treatment would be helpful. The overall low timeline and modest consequences scores, and high treatment and personal control scores, would imply that this cohort might be over-optimistic about their treatment and recovery. Interestingly, we found no relationship between treatment control and consequences scores as a clinician would generally expect. There was no obvious explanation for this observation.
Age, gender, hand dominance and illness perceptions Younger patients reported more symptoms related to the injury (higher identity score) (r Z 0.294, p < 0.05). There was a positive correlation between age and timeline score, indicating that younger patients believed their condition would last a limited duration (r Z þ0.269, p < 0.05). Those with injuries to the dominant hand (t Z 2.648, p Z 0.01) and female patients (t Z 2.833, p Z 0.006) had a significantly higher DASH score, but showed no difference in the HISS score. Patients with injuries to the dominant hand also attributed more symptoms related to their injuries (t Z 3.390, p Z 0.001), believed that their symptoms would come and go in cycles (t Z 2.052, p Z 0.045) and were less able to understand or make sense of their condition (lower illness coherence score, t Z 2.061, p Z 0.044).
Discussion Overall, the cohort was optimistic about their treatment and duration of recovery (high treatment control score and low timeline). Beliefs of negative consequences, chronic/ cyclical duration and low illness coherence were linked
Illness representations in hand injury Table 3
931
Intercorrelations between DASH, HISS and IPQ-R scores DASH
HISS
Identity Timeline (Acute/ Chronic)
Consequences Personal control
HISS 0.131 Identity 0.228 0.119 Timeline (Acute/Chronic) 0.237 0.068 0.025 Consequences 0.211 0.164 0.266* 0.532*** Personal Control 0.042 0.007 0.027 0.278* 0.033 Treatment Control 0.057 0.014 0.132 0.542*** 0.207 Illness Coherence 0.126 0.104 0.044 0.262 0.169 Timeline (Cyclical) 0.126 0.126 0.054 0.461*** 0.553*** Emotional Representation 0.186 0.011 0.296* 0.273* 0.519***
Treatment Illness Timeline control coherence (Cyclical)
0.503*** 0.040 0.285* 0.127 0.336* 0.048 0.165
0.436** 0.279*
0.545***
*** p < 0.001. ** p < 0.01. * p < 0.05.
with negative emotional response. High illness identity was associated with perception of pessimistic outcome (high consequences score) and negative emotional response. Research has examined the way in which patients cope with various illnesses. Patients can vary widely in their perceptions and subsequently, the manner in which they respond and adapt to health threats.6,25e27 In this study, we examined the illness beliefs in a cohort of patients with hand injury. It is undeniable that hand trauma can result in considerable burden and place stress on the health, social, economic and psychological well-being of the patient.4,28 Exploring the perceptions of patients may help us to manage any negative illness beliefs and provide a strategy for coping and adjustment.7 One interesting finding in this study was that neither the HISS nor the DASH score correlates with any of the illness perception components. This suggests that the patients might have pre-formed beliefs about the course and outlook of hand injury, and the injury which they sustained did not necessarily alter these existing (fixed) beliefs. In fact, we found that the majority were very optimistic and perceived that their injury would last for a limited time and be without severe consequences. These unrealistic beliefs must be altered because such inflated expectation could only lead to a mismatch in expectation, leading to disappointment, negative coping behaviour and negative emotional response.26,29e31 In this study, we found that the small subset with severe injury (HISS Grade III or higher) were more optimistic about recovery than the rest of the cohort. Further research is needed in patients with severe injury, as they could be the potential target for psychological intervention to overcome their unrealistic beliefs. It is noteworthy that our study found that illness identity was linked to beliefs of serious consequences and negative emotional response. Although interpretation of this finding was limited by the cross-sectional nature of the study, we suggest that lessening symptoms during the pre- and postoperative period might alter these pessimistic beliefs. As over 90% of our patients experienced pain in the acute setting, reducing pain (e.g. generous analgesia and fracture splinting) might help to alter these negative beliefs. Only a prospective longitudinal study assessing the adequacy of symptom control would clarify this. It is not known why
a large number of patients attributed sleep difficulties as part of their illness identity. We suspect that patients might have interpreted their anxiety about their surgery as a cause of sleep difficulties. It is likely that patients’ behaviour and coping strategy would change throughout the recovery period. We suspect pre-injury perceptions would influence this to a certain extent. In this study, we evaluated illness beliefs in the acute trauma setting. However, it is imperative that future research examines whether these beliefs would change after surgery and a period of recovery. The post-operative period is crucial as rehabilitation with hand therapy relies on patient compliance. Negative coping behaviour and pessimistic beliefs about the benefit of therapy during this period would lead to poor adherence and a less optimal outcome. Despite the limitation of the present study, it provides information on the nature of illness representations in this patient group and provides a foundation for further longitudinal research in the hand trauma setting. In summary, there was no correlation between the various components of illness beliefs and subjective or objective severity, suggesting that patients’ perceptions were not influenced by the recent trauma experience. Patients in this cohort were optimistic about what treatment could offer and their subsequent recovery. There was some evidence to suggest that patients with severe injury were over-optimistic and these findings suggest that there could be a role for psychological intervention (e.g. counselling) to modify any unrealistic expectations and negative emotional response in order to improve compliance to treatment and rehabilitation. In conclusion, the illness beliefs that patients hold in relation to their hand injuries do not necessarily relate to the severity of the injury. Further research is needed to evaluate and understand the role of illness perception in hand injury, especially during the post-operative recovery period.
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