The Presence and Impact of Stress Reactions on Disability among Patients with Arm Injury

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CREDIT ARTICLE #180.

The Presence and Impact of Stress Reactions on Disability among Patients with Arm Injury Jane Bear-Lehman, PhD, OTR/L, FAOTA Sally E. Poole, MA, OT/L, CHT Department of Occupational Therapy, NYU Steinhardt, New York, New York

A traumatic arm injury is a sudden and serious event that may be life altering. Often, the individual is neither mentally nor physically prepared for the injury. Although the physical injury is localized to the arm, it may affect the patient’s overall health and well-being.1 Injury to the hand can have physical and psychosocial implications.2e4 Psychosocial problems may interfere with the recovery process and could adversely impact the patient’s work, daily activities, life roles, habits, and independence.5 Physical rehabilitation strategies are plentiful in the hand therapy literature, but there has been little direct examination of the social and psychological impact of traumatic armehand injuries. The patient’s capacity to engage in the therapeutic process is an important determinant of outcome in hand therapy.6 The motivation to recover after an arm injury depends on his or her ability to adapt to the many changes the injury has caused. The effects of stress may influence motivation to engage in therapy. The umbrella term ‘‘stress’’ entails the consequence or the reaction to a stressful situation that may threaten the individual’s internal sense of balance or homeostasis.7 The regulatory system then becomes unbalanced.8 Correspondence and reprint requests to Jane Bear-Lehman, PhD, OTR/L, FAOTA, Department of Occupational Therapy, NYU Steinhardt, 35 West 4th Street, New York, NY 10012; e-mail: . 0894-1130/$ - see front matter Ó 2011 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. doi:10.1016/j.jht.2010.09.069

ABSTRACT: This study explores the prevalence and types of stress reactions and their impact on self-perceived disability among armehand-injured patients. It tested the null hypothesis that there is no correlation between stress reactions after traumatic hand injury and arm-specific disability. In a prospective cohort of 24 patients, stress reactions were measured using the Impact of Events Scale-Revised (IES-R), and arm-specific disability was measured using the QuickDASH, an average of 7.5 months (range: 1.5e33 months) after injury. Type of injury, length of time since injury, and gender did not influence scores on the IES-R or the QuickDASH. The IES-R subscales of intrusion and hyperarousal correlated with QuickDASH scores (intrusion: r ¼ 0.57, p ¼ 0.004; hyperarousal: r ¼ 0.45, p ¼ 0.029). These findings suggest that the patient may require attention to learn how to engage in the therapy process while experiencing stress reactions. J HAND THER. 2011;24:89–94.

The stressor is the situation that caused the stress reaction. It is the stress reaction, more than the stressor, which jeopardizes homeostasis.9 A stress reaction occurs when an event or change is deemed threatening and exceeds the individual’s ability to respond in a healthy manner.10 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 of 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 the avoidance of watching wounddressing changes, hiding the hand, or not complying with the home exercise program. Those individuals who present a hyperarousal stress reaction tend to present as angry, with hypervigilance, changes in mood, and increased irritability.11,12 Additionally, the patient’s capacity to cope and adapt to a changed functional status and/or cosmetic appearance, reexperiencing of the traumatic experience, dependency on others, involuntary inactivity, or uncertainty about the future, all can exacerbate stress reaction levels and impede recovery.13 Increased appreciation of and attention to the presence of stress, stressors, and stress reactions among patients we treat may improve care. The treatment of patients experiencing stress reactions may require a AprileJune 2011

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therapeutic relationship that deliberately considers the patient’s capacity to participate in the therapy program. Intrusive and avoidant stress reactions may not be as obvious as hyperarousal stress reactions, such as irritability or anger. As a first step, this study explores the presence and type of stress reactions among armehand-injured patients and the correlation of these reactions with armehand-specific disability.

METHODS Participants Subjects were recruited from four private practice hand therapy offices in New York and New Jersey. Inclusion criteria were 1) acute traumatic armehand injury in active treatment at the time of the study, 2) 18 years of age or older, and 3) ability to read and understand English. Patients who suffered a cumulative trauma or congenital or acquired disease were excluded from the participant selection.

Questionnaires Impact of Event Scale The Impact of Events Scale-Revised (IES-R) parallels the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for posttraumatic stress disorder (PTSD)15 and is one of the most widely used self-report measures of stress after trauma14 (Figure 1). It is grounded in Horowitz’s model of emotional processing after a trauma.15 The IES-R is composed of 22 statements relating to stress reactions in three domains: intrusion, avoidance, and hyperarousal measured on a five-point Likert scale— 0 ¼ not at all, 1 ¼ a little bit, 2 ¼ moderately, 3 ¼ quite a bit, and 4 ¼ extremely. The overall total range of scores is between 0 (not at all) and 88 (extremely). The threshold of clinical concern on the IES-R for PTSD is an overall total IES-R score of 24 or greater. In addition to an overall total score, subscale scores for intrusion, avoidance, and hyperarousal can be determined based on the average of the item response for each of the

13 14 15 16 17 18 19 20 21 22

Extremely

12

Quite a bit

6 7 8 9 10 11

Moderately

5

Any reminder brought back feelings about it. I had trouble staying asleep. Other things kept making me think about it. I felt irritable and angry. I avoided letting myself get upset when I thought about it or was reminded of it. I thought about it when I didn’t mean to. I felt as if it hadn’t happened or wasn’t real. I stayed away from reminders about it. Pictures about it popped into my mind. I was jumpy and easily startled. I tried not to think about it. I was aware that I still had a lot of feelings about it, but I didn’t deal with them. My feelings about it were kind of numb. I found myself acting or feeling like I was back at that time. I had trouble falling asleep. I had waves of strong feelings about it. I tried to remove it from my memory. I had trouble concentrating. Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart. I had dreams about it. I felt watchful and on guard. I tried not to talk about it.

A little bit

1 2 3 4

Not at all

Instructions: The following is a list of difficulties people sometimes have after stressful life events. Please read each item, and then indicate how distressing each difficulty has been for you during the past 7 days with respect to the disaster. How much were you distressed or bothered by these difficulties?

0 0 0 0

1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

0

1

2

3

4

0 0 0 0 0 0

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

0

1

2

3

4

0 0 0 0 0 0

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

0

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2

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0 0 0

1 1 1

2 2 2

3 3 3

4 4 4

FIGURE 1. Impact of Events Scale-Revised (IES-R). The IES-R total score is determined by the responses to all 22 items; individual subscale results are determined based on the response to the eight intrusion items (1, 2, 3, 6, 9, 14, 16, and 20), eight avoidance items (5, 7, 8, 11, 12, 13, 17, and 22), and six hyperarousal items (4, 10, 15, 18, 19, and 21).15,17 90

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designated subscale items embedded within the 22 items on the IES-R (Figure 1). The IES-R was shown to be a valid tool when administered within seven days after a specific traumatic life event with strong testeretest reliability (correlation coefficients between 0.89 and 0.94) for the three subscales: intrusion, avoidance, and hyperarousal.17,19 The scale’s discriminative validity suggests that the measure can differentiate between varieties of traumatized groups from nontraumatized groups in general population studies.17 The three subscales show substantial intercorrelation (correlation coefficients between 0.52 and 0.87), with high levels of internal consistency estimate of reliability of test scores (intrusion: Cronbach’s a ¼ 0.87e0.94; avoidance: Cronbach’s a ¼ 0.84e0.87; and hyperarousal: Cronbach’s a ¼ 0.79e0.91).16e19 Intrusion and avoidance subscales identify important differences in the clinical response to traumatic injuries.17 The hyperarousal scale has good predictive validity regarding trauma.20 QuickDASH The QuickDASH is an 11-question shortened version of the full 30-question Disabilities of Arm, Shoulder, and Hand (DASH), norm-referenced, self-report questionnaire, developed by the Institute for Work & Health in Canada.21,22 The QuickDASH and the DASH are routinely used to assess arm-specific disability. The QuickDASH consists of 11 items scored on Likert scales between 1 ¼ no difficulty and 5 ¼ unable. The scores are scaled between 0 representing no disability and 100 representing complete arm disability. The QuickDASH scale is a more efficient version of the DASH, and it has retained the psychometric measurement properties of the DASH.22e24 The internal consistency of the DASH is 0.96.25 The QuickDASH has testeretest reliability that is consistent with the DASH—intraclass correlation $ 0.94, r ¼ 0.80.21

Study Procedures Owners of four of occupational therapy/hand therapy private practice outpatient clinics agreed to participate in this study. Letters of participant consent along with the IES-R, QuickDASH, and demographic questionnaire were approved by our institutional review board (University Committee on Activities Involving Human Subjects (UCAIHS) 10-0035). In October 2009, 20 packets containing the Demographic Questionnaire, IES-R, QuickDASH, two copies of the participant consent form, and a return stamped envelope addressed to the researchers were given to each of the four participating clinics. When a patient fitting the inclusion criteria was identified, the therapist explained the purpose of the study and provided the patient with a written invitation describing the

research project. When a patient agreed to participate, he or she was given a research packet and asked to complete the material in private and return his or her response directly to the researchers in the envelope provided. The patient was asked to sign one copy of the participant consent form, which included the purpose of the study; participant expectations; risks and benefits; confidentiality; voluntary participation, including the right to withdrawal at anytime and opportunity to omit questions. One copy of the consent form was kept by the participant.

Statistical Analysis Pearson’s correlation coefficients were used to test for correlations between continuous variables (e.g., between QuickDASH scores and the total IES-R score as well as the scores on the individual subscales). Oneway analysis of variance was used to test for significant differences in DASH and IES-R with respect to categorical explanatory variables, such as gender and injury type. Significance level was set for p-value (two tailed) less than 0.05.

RESULTS A total of 10 women and 14 men between the ages of 25 and 85 years, who sustained a traumatic injury, participated in the study. Of the 25 questionnaires received, only one contained incomplete data. The total number of patients given a study packet—and, thus, the response rate—is unknown. The participants reported their injuries as follows: distal radial fracture (n ¼ 10); bilateral wrist fractures (n ¼ 2); elbow fracture (n ¼ 1); finger sprain (n ¼ 2); wrist sprain (n ¼ 1); tendon laceration (n ¼ 1); palmar skin laceration (n ¼ 3); wrist-level tendon, nerve, and artery laceration (n ¼ 1); thumb amputation (n ¼ 1); and a hydraulic gun injury (n ¼ 1). Because the study was based on anonymous self-report by the study subjects, we cannot be more specific about the injuries. Although women had a higher average QuickDASH score (52.5 compared with 38 for men), the differences were not statistically significant with the numbers available. There were no significant differences in QuickDASH with respect to type of injury or length of time since injury. The average total IES-R score was 17.9 (standard deviation: 12.6; range: 0e42). Seven patients in the study scored in the area of clinical concern for PTSD (IES-R $ 24). The item scores for each of the three subscales ranged between 0 (not at all) and 2 (moderately), and the mean subscale scores for the patients in the study were all less than 1; the mean intrusion ¼ 0.94; mean hyperarousal ¼ 0.68; and mean avoidance ¼ 0.76 (Table 1). There were no significant differences in IES-R outcome scores based on type of injury, time since AprileJune 2011

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TABLE 1. IES-R and QuickDASH Outcomes for 24 Patients Measurement Instrument

Mean Scores

Standard Deviation

Range

IES-R: intrusion subscale IES-R: avoidance subscale IES-R: hyperarousal subscale Overall IES-R QuickDASH

0.94 0.76 0.68 17.9 44

0.66 0.67 0.53 12.5 24.3

0e2.00 0e2.00 0e2.00 0e42 2e93

IES-R ¼ Impact of Events Scale-Revised; QuickDASH ¼ 11-question shortened version of the full 30-question Disabilities of Arm, Shoulder, and Hand Questionnaire.

injury, or gender of the patient. QuickDASH correlated with total (overall) IES-R score (r ¼ 0.51; p ¼ 0.016) and the intrusion (r ¼ 0.57; p ¼ 0.004) and hyperarousal (r ¼ 0.45; p ¼ 0.029) subscales but not with the avoidance subscale (Table 2).

DISCUSSION We identified the presence of stress reactions and the type of stressful reactions among our participants who suffered armehand injuries on the IES-R. Our participants yielded subthreshold indicators of stressful reactions on the IES-R subscales of intrusion and hyperarousal. Because the IES-R survey was completed only once, there was no opportunity to compare expressions of stressful reactions over time. Stress reaction, as measured using the IES-R, correlates with arm-specific disability (QuickDASH) among patients with a traumatic injury, although only a subset of participants (7 of 24; 29%) met the threshold score for clinical concern. Although we collected self-reported data an average of 7.5 months after injury, our identification of the presence of both intrusive and avoidance symptoms that impede the recovery process compares with those of Grunert et al.3,26 and Gustafsson et al.,13 who reported on patients soon after injury; studied various types of injuries and intervention contexts; and directly interviewed their patients. For example, in a follow-up study, Grunert et al.26 reported that both intrusive and hyperarousal symptoms, noted in TABLE 2. Correlation of QuickDASH with IES-R and its Subsystems IES-R Total and 3 Subsystems IES-R total Intrusion Hyperarousal Avoidance

QuickDASH (r)

p-Value

0.51* 0.57y 0.45y 0.35

0.016 0.004 0.029 0.11

IES-R ¼ Impact of Events Scale-Revised; QuickDASH ¼ 11-question shortened version of the full 30-question Disabilities of Arm, Shoulder, and Hand Questionnaire. *Correlation is significant at the 0.05 level (two tailed). yCorrelation is significant at the 0.01 level (two tailed).

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94% of their 67 patients soon after the work-related injury, were still persistent 18 months later, and that psychological intervention helped with adjustment. Furthermore, stress reaction intrusive and hyperarousal symptoms were evident in the early acute hand therapy patients who participated in a small qualitative study based on grounded theory designed to gain insight about the process of adjustment.13 Neither Gustafsson’s13 well-controlled purposeful sampling study nor Grunert et al’s3,26 sample of convenience study used specific measure of stress reactions. To date, there are no studies reported correlating the IES-R with the QuickDASH in traumatic armehandinjury patients.27,28 The positive correlation demonstrated between the total IES-R and the QuickDASH disability may indicate that, as stress reaction increases, the perceived disability also increases. A rise in stress reaction along with a rise in perceived disability could impede an individual’s capacity to fully participate in the therapy process. The correlation between the intrusion and hyperarousal IES-R subsystems scores with the QuickDASH disability score may be indicative of the negative impact on the patient’s self-report of functional performance and perceived disability. This study should be interpreted in light of several limitations. First, we had limited power with only 24 patients and would consider this pilot work. Second, this was an observational study and patients were in different stages of the recovery process. Third, as an exempt institutional review board study that does not allow researchers’ access to patient identifiers, the study relied exclusively on self-reported data that could not be verified for specificity or accuracy. Finally, we provided the four-hand therapy centers each with 20 study questionnaire packets (total of 80 packets were distributed), and the therapists were responsible for asking their patients to participate in the study. We presume that many patients did not return their questionnaires, which may have resulted in a response bias. We tend to think of the psychosocial aspects of illness as dichotomous (all or none). This is a false dichotomy, because we all experience some level of emotional response when we are ill or injured. Stress reactions are part of this normal response. In our study, nearly a third of patients met the criteria for clinical concern, but the correlation of stress with disability was seen across the spectrum of stress reactions, including those patients with stress below this threshold level. Greater stress creates greater disability, even when that stress is relatively minor. A person who is plagued by flashbacks and disturbing dreams may be too exhausted or overwhelmed by the intrusive memories to maintain focus and energy in therapy. Anger and agitation may hinder concentration on and registration of the treatment regimen. Stress reactions among patients who have sustained a

traumatic armehand injury predominate in the domains of intrusion and hyperarousal. In our opinion, the stress reactions of intrusion and hyperarousal hinder participation in therapy. The findings of this study suggest that we need to be mindful of the influence of stress reactions on recovery from injury. 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. Acknowledgments The authors wish to thank the following NYU OT (New York University Occupational Therapy) graduate students for their assistance with this project: A. Rubin (Brand), L. McConachie, E. Michel, K. Rabinowicz, S. Pomper (Sandhaus), S. Seah, P. Varkey, and T. Wertentheil. They appreciate the support of the participating clinicians and their patients.

REFERENCES 1. Brown PW. Body and soul. J Hand Ther. 1996;9:201–2. 2. Gilbert S. Implication of severe trauma to the hand. Prof Nurse. 1996;11:368–70. 3. Grunert BK, Smith CJ, Devine CA, et al. Early psychological aspects of severe hand injury. J Hand Surg Br. 1988;13:177–80. 4. Johnson RK. Psychological assessment of patients with industrial hand injuries. Hand Clin. 1993;9:221–9. 5. Hasselkus B. The Meaning of Everyday Occupation. Thorofare, NJ: Slack, 2002. 6. Brown PW. The role of motivation in the recovery of the hand. In: Kasdan ML (ed). Occupational Hand & Upper Extremity Injuries and Diseases. Philadelphia, PA: Hanley & Belfus, 1998. pp. 5–14. 7. Antonovsky A. Health, Stress and Coping. London, UK: JosseyBass, 1979. 8. White BP. Psychobiological factors. In: Crepeau EB, Cohn ES, Boyt Schell BA (eds). Willard & Spackman’s Occupational Therapy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009. pp. 715–38. 9. Aardal-Eriksson E, Eriksson TE, Thorell LH. Salivary cortisol, posttraumatic stress symptoms, and general health in the acute phase and during 9-month follow-up. Biol Psychiatry. 2001;50: 986–93. 10. Lazarus R, Folkman S. Stress, Appraisal, and Coping. New York, NY: Springer Publishing Company, 1984.

11. Grob M, Papadopulos NA, Zimmermann A, Biemer E, Kovacs L. The psychological impact of severe hand injury. J Hand Surg Eur Vol. 2008;33:358–62. 12. Weis JM, Grunert BK. Post-traumatic stress disorder following traumatic injuries in adults. WMJ. 2004;103:69–72. 13. Gustafsson M, Peerson L, Amilon A. A qualitative study of stress factors in the early stage of acute traumatic hand injury. J Adv Nurs. 2000;32:1333–40. 14. Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosom Med. 1979;41:209–18. 15. Horowitz MJ. Stress Response Syndromes. 1st ed. New York, NY: Jason Aronson, 1976. 16. Beck JG, Grant DM, Read JP, et al. The impact of event scale—revised: psychometric properties in a sample of motor vehicle accident survivors. J Anxiety Disord. 2008;22:187–98. 17. Weiss D, Marmar C. The impact of event scale—revised. In: Wilson J, Keane TM (eds). Assessing Psychological Trauma and PTSD. New York, NY: Guilford, 1997. pp. 399–411. 18. Hyer K, Brown LM. The impact of event scale—revised: a quick measure of a patient’s response to trauma. Am J Nurs. 2008;108:60–8. 19. Creamer M, Bell R, Falilla S. Psychometric properties of the impact of event scale—revised. Behav Res Ther. 2002;41:1489–96. 20. Briere J. Psychological Assessment of Adult Posttraumatic States. Washington, DC: American Psychological Association, 1997. 21. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128–46. 22. Wong JYP, Fung BKK, Chu MML, Chan RKY. The use of Disabilities of the Arm, Shoulder, and Hand Questionnaire in rehabilitation after acute traumatic injuries. J Hand Ther. 2007;20:49–56. 23. Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87:1038–46. 24. Gummesson C, Ward MM, Atroshi I. The shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006;7:44. 25. Solway S, Beaton DE, McConnell S, Bombardier C. The DASH Outcome Measure User’s Manual. 2nd ed. Toronto, Canada: Institute for Work & Health, 2002. 26. Grunert BK, Devine CA, Matloub HS, et al. Psychological adjustment following work-related hand injury: 18-month follow-up. Ann Plast Surg. 1992;29:537–42. 27. Jacquet JB, Kalmijn S, Kuypers PDL, Hofman A, Passchier J, Hovius SER. Early psychological stress after forearm nerve injuries: a predictor for long-term functional outcome and return to productivity. Ann Plast Surg. 2002;49:82–90. 28. Jacquet JB, Jagt IVD, Kuypers PDL, Schreuders TAR, Kalmijn S, Hovius SER. Spaghetti wrist trauma: functional recovery, return to work, and psychological effects. Plast Reconstr Surg. 2005;115:1609–17.

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JHT Read for Credit Quiz: Article #180

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question. #1. The primary purpose of this study was to a. describe interventions for arm-hand patients in stress b. propose a screening tool to detect stress reactions among arm-hand patients. c. test the presence of Post-Traumatic Stress Disorder among arm-hand patients d. determine whether the QuickDash identifies stress and stress reactions #2. Stress reactions were determined by a. self-report on the IES-R Impact of Events Scale b. therapists observational data c. self-report on the QuickDash d. the SF-36 #3. The IES-R (Impact of Events Scale) a. has been widely used for arm-hand patients in therapy

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b. has no theoretical basis c. has been correlated with the QuickDash d. parallels the DSM-IV criteria for PTSD (Post Traumatic Stress Disorder) #4. The subjects in the study a. all had suffered a traumatic hand injury within the last two months b. were interviewed by their treating therapist c. were sampled by convenience d. showed signs of Avoidance on the IES-R #5. The findings of the study indicate that the majority of the arm-hand patients demonstrated a. no measureable stress reactions b. had sub-threshold stress reactions of the IES-R Intrusion and Hyperarousal scales c. an IES-R score $ 24 indicating clinical concern for PTSD d. disability scores on the QuickDASH that did not correlate with scores on the IES-R When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.