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Psychological distress associated with algodystrophy
PSYCHOLOGICAL DISTRESS ASSOCIATED WITH ALGODYSTROPHY J. FIELD and F. V. GARDNER
From Bristol Royal Infirmary, Bristol, UK We have carried out a prospective study of the level of psychological distress in patients with Colles' fractures. Those who developed algodystrophy did not show increased distress before the onset of the condition.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 1." 100-101 Algodystrophy (reflex sympathetic dystrophy or Sudeck's atrophy) is a syndrome consisting of excessive pain, loss of joint mobility, swelling and temperature, colour and sudomotor changes (collectively referred to as vasomotor instability [VMI]). Later, atrophy of the skin and soft tissues may occur with joint contractures and regional osteoporosis. The most common precipitating cause is trauma (Doury et al, 1981) and it has been shown that the incidence after Colles' fracture, when specifically sought, is between 25% and 30% (Atkins et al, 1989). The symptom that is most predominant is pain. In algodystrophy the disparity between the degree of pain and the physical examination may lead the physician to think that the pain is of a psychogenic origin. Many authors have linked algodystrophy with psychological abnormality-(de Takats, 1937; de Takats and Miller, 1943; Pak et al, 1970; Bernstein et al, 1978). However, this link is disputed by others (Evans, 1947; Kleinert et al, 1973; Rosen and Graham, 1957; Wilson, 1981). Explanations for this discrepancy may be that only chronic cases are referred to a psychiatrist, or chronic pain may promote psychological distress, or mild algodystrophy in the presence of an inherent psychological disturbance produces a poor result. Some report recovery o f the emotional disturbance with successful treatment of the algodystrophy (Echlin et al, 1945, Sunderland, 1976). However, Dworkin et al (1992) found that those developing chronic pain had a higher level of emotional disturbance in a prospective study of patients with herpes zoster induced shingles. It was the object of this study to analyse prospectively the psychological profile of patients after Colles' fracture, and to see if those patients developing algodystrophy had a different psychological profile to those who did not.
65 years 6 months). A formal diagnosis of algodystrophy was made at 9 weeks (Atkins et al, 1990), by the presence of all four of the following diagnostic criteria:
Finger tenderness. This was measured using a dolorimeter which gives a dolorimetry ratio of abnormal to normal hands (McCarty et al, 1968). This method has been shown previously to be reproducible (Atkins et al, 1989). Swelling. Digit circumference was measured using an arthrocircameter (Willkens et al, 1973). Hand swelling was measured using water displacement. Range offinger movement. Finger stiffness was quantified by measuring the range of movement of all joints in the fingers of both hands using a goniometer. A total range of movement for each hand was obtained by adding the value for each joint. The value for joint stiffness was found by subtracting one hand total from the other. Vasomotor instability (VMI). Vasomotor instability was assessed by a questionnaire (Atkins et al, 1989). Each feature was scored as 0 (absent) or 1 (present); the sum of these scores was used to give a semiquantitative assessment of VMI. Each of the 100 patients examined in this study was subjected to a self administered psychological questionnaire (General health questionnaire--described and validated by Goldberg [1972]) at both 1 week and 3 months after fracture. The GHQ 30 test gives a quantitative estimate of the degree of psychiatric disturbance. (A clinical psychologist advised on the most appropriate questionnaire). Using the simple "Likert method" of scoring (Goldberg, 1972), a value of 39 or more indicates significant psychological distress. The diagnosis of algodystrophy was made at 9 weeks and at 3 months the psychological assessment of those with and without algodystrophy could be made to determine whether there was a difference in psychological profiles. It was also then possible to look at the groups' psychological profiles retrospectively to determine whether there were any personality differences before developing the syndrome. All studies had prior local ethical committee approval. All patients gave informed consent to participation in
PATIENTS AND METHODS One hundred consecutive patients with Colles' fracture were examined 1 week, 5 weeks and 9 weeks after fracture. At 1 week, patients were examined in the plaster of Paris cast. There were 80 women and 20 men. All patients were aged 50 years or over (mean age was 100
PSYCHOLOGICAL DISTRESS AND ALGODYSTROPHY
101
the study. N o change in the clinical management was caused by their participation.
Statistical analysis Comparison of values between groups was performed using Anova analysis of variance and then Student's paired t-test as appropriate. The significance of difference between proportions was assessed using the Z2 test with Yates' correction. Values are expressed as mean (SEM). RESULTS At 9 weeks, 24 patients had all four features of the condition and were diagnosed as having algodystrophy; 28 patients had one, two or three features and were regarded as borderline and 48 cases had no features and were referred to as normal. For all the cases the average score at the first visit was 29 (t.2). The average score at the second (3-month) visit was slightly lower at 25 (1.2). This difference is significant (P--0.012) indicating that breaking an arm causes a degree of distress. Of the 93 patients who completed the questionnaire on both occasions, 13 had a score of >39 at the first visit; of these, three went on to develop algodystrophy. This was not a significant increase (P>0.05). At the 3-month test, nine patients had a score of > 39. Two of these had algodystrophy and only one of those cases had a score of below 39 on the first test. Four of the nine cases had scores of > 39 at the first visit. When the patients were split into the three diagnostic categories of algodystrophy, normal or borderline, there was no significant differences between the groups on either test. On comparing scores at each visit the only significant change was in the normal group in which there was an improved score over the 3 month period (Table 1). DISCUSSION Wide differences in prevalence rates of psychiatric disturbance are due in large part to differences in methods used for case identification. The best method for case identification is intera~iew by a single psychologist. However, this was not feasible in this study. The advantages of self-administered questionnaires are that large Table 1 - - G H Q Mean ( S E M )
30 scores at each visit for each diagnostic group.
Diagnostic group
1 week
12 weeks
Algodystrophy (n=22) Normal (n=45)
27 (2.1) 30 (2.1)
27 (3.1) 25 (1.6)
Borderline (n = 26)
28 (2.7)
24 (2.0)
Signif NS P= 0.01 NS
numbers of subjects can be studied, the method is cheap and not time-consuming and interobserver bias is excluded. With these limitations in the method of assessment some conclusions can be drawn. Sustaining a fracture is a stressful experience. The "normal" group become less distressed as the fracture heals and this improvement is significant, patients who develop algodystrophy do not improve bu[ from these figures a much larger study would be necessary to prove the hypothesis that the condition worsens the psychological profile. Patients developing algodystrophy after Colles' fracture have as normal a psychological profile as those who do not using this particular questionnaire. However, the development of the disorder may have an impact on their levels of psychological distress. It may be that the development of the syndrome and the fact that the clinician is uncertain both of the nature of condition and methods of treatment make the patient appear psychologically disturbed.
References ATKINS R M, DUCKWORTH T and KANIS J A (1989). Algodystrophy following Colles' fracture. Journal of Hand Surgery, 14B: 161-164. ATKINS R M, DUCKWORTH T and KANIS J A (1990). Features of algodystrophy after Colles' fracture. Journal of Bone and Joint Surgery, 72B: 105-110. BERNSTEIN B H, SINGSEN B, KENT J J e t al (1978). Reflex neurovascular dystrophy in children. Journal of Pediatrics, 93: 2t 1-215. DOURY P, DIRHEIMER Y, PATTIN S. Algodystrophy: diagnosis and therapy of a frequent disease of the locomotor apparatus. Berlin, Springer-Verlag 1981. DWORKIN R H, HARTSTEIN G, ROSNER H L, WALTHER R R, SWEENEY E W and BRAND L (1992). A high risk method for studying psychosocial antecedents of chronic pain: the prospective investigation of herpes zoster. Journal of Abnormal Psychology, 101: 200-205. ECHLIN F, OWENS F M and WELLS W L (1945). Observations on "major" and "minor" causalgia. Archives of Neurology, 62: 183-203. EVANS J A (1947). Reflex sympathetic dystrophy: a report of 57 cases. Annals of Internal Medicine, 26: 417-426. GOLDBERG D. The detection of psychological illness by questionnaire. London, Oxford University Press, 1972. KLEINERT H E, COLE N M, WAYNE L, HARVEY R, KUTZ J E and ATASOY E (1973). Post-traumatic sympathetic dystrophy. Orthopedic Clinics of North America, 4: 917-927. McCARTY D J, GATTER R A and PHELPS P (1968). A dolorimeter for quantification of articular tenderness. Arthritis and Rheumatism, 8: 551-559. PAK T J, MARTIN G M, MAGNESS J L and KAVANAUGH G J (1970). Reflex sympathetic dystrophy: review of 140 cases. Minnesota Medicine; 53:507 512. ROSEN P S and GRAHAM W (1957). The shoulder-hand syndrome: historical review with observations on 73 patients. Canadian Medical Association Journal, 77: 86-91. SUNDERLAND S (1976). Pain mechanisms in causalgia. Journal of Neurology, Neurosurgery and Psychiatry, 39: 471-480. de TAKATS G (1937). Reflex dystrophy of the extremities. Archives of Surgery, 34: 939-956. de TAKATS G and MILLER D S (1943). Post traumatic dystrophy of the extremities. A chronic vasodilator mechanism. Archives of Surgery, 46: 469-479. WILLKENS R F, GLEICHERT J E and GADE E T (1973). Proximal interphalangeal joint measurement by arthrocircameter. Annals of the Rheumatic Diseases, 32: 585-586. WILSON R L (1981 ). Management of pain following peripheraI nerve injuries. Orthopedic Clinics of North America, 12: 343-358.
Received: 20 February 1996 Accepted after revision: 13 June 1996 Mr J. Field, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK. © 1997 The British Societyfor Surgery of the Hand
From Bristol Royal Infirmary, Bristol, UK We have carried out a prospective study of the level of psychological distress in patients with Colles' fractures. Those who developed algodystrophy did not show increased distress before the onset of the condition.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 1." 100-101 Algodystrophy (reflex sympathetic dystrophy or Sudeck's atrophy) is a syndrome consisting of excessive pain, loss of joint mobility, swelling and temperature, colour and sudomotor changes (collectively referred to as vasomotor instability [VMI]). Later, atrophy of the skin and soft tissues may occur with joint contractures and regional osteoporosis. The most common precipitating cause is trauma (Doury et al, 1981) and it has been shown that the incidence after Colles' fracture, when specifically sought, is between 25% and 30% (Atkins et al, 1989). The symptom that is most predominant is pain. In algodystrophy the disparity between the degree of pain and the physical examination may lead the physician to think that the pain is of a psychogenic origin. Many authors have linked algodystrophy with psychological abnormality-(de Takats, 1937; de Takats and Miller, 1943; Pak et al, 1970; Bernstein et al, 1978). However, this link is disputed by others (Evans, 1947; Kleinert et al, 1973; Rosen and Graham, 1957; Wilson, 1981). Explanations for this discrepancy may be that only chronic cases are referred to a psychiatrist, or chronic pain may promote psychological distress, or mild algodystrophy in the presence of an inherent psychological disturbance produces a poor result. Some report recovery o f the emotional disturbance with successful treatment of the algodystrophy (Echlin et al, 1945, Sunderland, 1976). However, Dworkin et al (1992) found that those developing chronic pain had a higher level of emotional disturbance in a prospective study of patients with herpes zoster induced shingles. It was the object of this study to analyse prospectively the psychological profile of patients after Colles' fracture, and to see if those patients developing algodystrophy had a different psychological profile to those who did not.
65 years 6 months). A formal diagnosis of algodystrophy was made at 9 weeks (Atkins et al, 1990), by the presence of all four of the following diagnostic criteria:
Finger tenderness. This was measured using a dolorimeter which gives a dolorimetry ratio of abnormal to normal hands (McCarty et al, 1968). This method has been shown previously to be reproducible (Atkins et al, 1989). Swelling. Digit circumference was measured using an arthrocircameter (Willkens et al, 1973). Hand swelling was measured using water displacement. Range offinger movement. Finger stiffness was quantified by measuring the range of movement of all joints in the fingers of both hands using a goniometer. A total range of movement for each hand was obtained by adding the value for each joint. The value for joint stiffness was found by subtracting one hand total from the other. Vasomotor instability (VMI). Vasomotor instability was assessed by a questionnaire (Atkins et al, 1989). Each feature was scored as 0 (absent) or 1 (present); the sum of these scores was used to give a semiquantitative assessment of VMI. Each of the 100 patients examined in this study was subjected to a self administered psychological questionnaire (General health questionnaire--described and validated by Goldberg [1972]) at both 1 week and 3 months after fracture. The GHQ 30 test gives a quantitative estimate of the degree of psychiatric disturbance. (A clinical psychologist advised on the most appropriate questionnaire). Using the simple "Likert method" of scoring (Goldberg, 1972), a value of 39 or more indicates significant psychological distress. The diagnosis of algodystrophy was made at 9 weeks and at 3 months the psychological assessment of those with and without algodystrophy could be made to determine whether there was a difference in psychological profiles. It was also then possible to look at the groups' psychological profiles retrospectively to determine whether there were any personality differences before developing the syndrome. All studies had prior local ethical committee approval. All patients gave informed consent to participation in
PATIENTS AND METHODS One hundred consecutive patients with Colles' fracture were examined 1 week, 5 weeks and 9 weeks after fracture. At 1 week, patients were examined in the plaster of Paris cast. There were 80 women and 20 men. All patients were aged 50 years or over (mean age was 100
PSYCHOLOGICAL DISTRESS AND ALGODYSTROPHY
101
the study. N o change in the clinical management was caused by their participation.
Statistical analysis Comparison of values between groups was performed using Anova analysis of variance and then Student's paired t-test as appropriate. The significance of difference between proportions was assessed using the Z2 test with Yates' correction. Values are expressed as mean (SEM). RESULTS At 9 weeks, 24 patients had all four features of the condition and were diagnosed as having algodystrophy; 28 patients had one, two or three features and were regarded as borderline and 48 cases had no features and were referred to as normal. For all the cases the average score at the first visit was 29 (t.2). The average score at the second (3-month) visit was slightly lower at 25 (1.2). This difference is significant (P--0.012) indicating that breaking an arm causes a degree of distress. Of the 93 patients who completed the questionnaire on both occasions, 13 had a score of >39 at the first visit; of these, three went on to develop algodystrophy. This was not a significant increase (P>0.05). At the 3-month test, nine patients had a score of > 39. Two of these had algodystrophy and only one of those cases had a score of below 39 on the first test. Four of the nine cases had scores of > 39 at the first visit. When the patients were split into the three diagnostic categories of algodystrophy, normal or borderline, there was no significant differences between the groups on either test. On comparing scores at each visit the only significant change was in the normal group in which there was an improved score over the 3 month period (Table 1). DISCUSSION Wide differences in prevalence rates of psychiatric disturbance are due in large part to differences in methods used for case identification. The best method for case identification is intera~iew by a single psychologist. However, this was not feasible in this study. The advantages of self-administered questionnaires are that large Table 1 - - G H Q Mean ( S E M )
30 scores at each visit for each diagnostic group.
Diagnostic group
1 week
12 weeks
Algodystrophy (n=22) Normal (n=45)
27 (2.1) 30 (2.1)
27 (3.1) 25 (1.6)
Borderline (n = 26)
28 (2.7)
24 (2.0)
Signif NS P= 0.01 NS
numbers of subjects can be studied, the method is cheap and not time-consuming and interobserver bias is excluded. With these limitations in the method of assessment some conclusions can be drawn. Sustaining a fracture is a stressful experience. The "normal" group become less distressed as the fracture heals and this improvement is significant, patients who develop algodystrophy do not improve bu[ from these figures a much larger study would be necessary to prove the hypothesis that the condition worsens the psychological profile. Patients developing algodystrophy after Colles' fracture have as normal a psychological profile as those who do not using this particular questionnaire. However, the development of the disorder may have an impact on their levels of psychological distress. It may be that the development of the syndrome and the fact that the clinician is uncertain both of the nature of condition and methods of treatment make the patient appear psychologically disturbed.
References ATKINS R M, DUCKWORTH T and KANIS J A (1989). Algodystrophy following Colles' fracture. Journal of Hand Surgery, 14B: 161-164. ATKINS R M, DUCKWORTH T and KANIS J A (1990). Features of algodystrophy after Colles' fracture. Journal of Bone and Joint Surgery, 72B: 105-110. BERNSTEIN B H, SINGSEN B, KENT J J e t al (1978). Reflex neurovascular dystrophy in children. Journal of Pediatrics, 93: 2t 1-215. DOURY P, DIRHEIMER Y, PATTIN S. Algodystrophy: diagnosis and therapy of a frequent disease of the locomotor apparatus. Berlin, Springer-Verlag 1981. DWORKIN R H, HARTSTEIN G, ROSNER H L, WALTHER R R, SWEENEY E W and BRAND L (1992). A high risk method for studying psychosocial antecedents of chronic pain: the prospective investigation of herpes zoster. Journal of Abnormal Psychology, 101: 200-205. ECHLIN F, OWENS F M and WELLS W L (1945). Observations on "major" and "minor" causalgia. Archives of Neurology, 62: 183-203. EVANS J A (1947). Reflex sympathetic dystrophy: a report of 57 cases. Annals of Internal Medicine, 26: 417-426. GOLDBERG D. The detection of psychological illness by questionnaire. London, Oxford University Press, 1972. KLEINERT H E, COLE N M, WAYNE L, HARVEY R, KUTZ J E and ATASOY E (1973). Post-traumatic sympathetic dystrophy. Orthopedic Clinics of North America, 4: 917-927. McCARTY D J, GATTER R A and PHELPS P (1968). A dolorimeter for quantification of articular tenderness. Arthritis and Rheumatism, 8: 551-559. PAK T J, MARTIN G M, MAGNESS J L and KAVANAUGH G J (1970). Reflex sympathetic dystrophy: review of 140 cases. Minnesota Medicine; 53:507 512. ROSEN P S and GRAHAM W (1957). The shoulder-hand syndrome: historical review with observations on 73 patients. Canadian Medical Association Journal, 77: 86-91. SUNDERLAND S (1976). Pain mechanisms in causalgia. Journal of Neurology, Neurosurgery and Psychiatry, 39: 471-480. de TAKATS G (1937). Reflex dystrophy of the extremities. Archives of Surgery, 34: 939-956. de TAKATS G and MILLER D S (1943). Post traumatic dystrophy of the extremities. A chronic vasodilator mechanism. Archives of Surgery, 46: 469-479. WILLKENS R F, GLEICHERT J E and GADE E T (1973). Proximal interphalangeal joint measurement by arthrocircameter. Annals of the Rheumatic Diseases, 32: 585-586. WILSON R L (1981 ). Management of pain following peripheraI nerve injuries. Orthopedic Clinics of North America, 12: 343-358.
Received: 20 February 1996 Accepted after revision: 13 June 1996 Mr J. Field, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK. © 1997 The British Societyfor Surgery of the Hand