- Email: [email protected]
The Relationship Between Catastrophic Thinking and Hand Diagram Areas
SCIENTIFIC ARTICLE
The Relationship Between Catastrophic Thinking and Hand Diagram Areas Ali Moradi, MD,*‡ Jos J. Mellema, MD,* Kamilcan Oflazoglu, BSc,* Aleksandr Isakov, MSc,* David Ring, MD, PhD,* Ana-Maria Vranceanu, PhD†
Purpose To evaluate the relationship between the total area marked on pain and numbness diagrams and psychosocial factors (depression, pain catastrophic thinking, and health anxiety). Methods A total of 155 patients marked painful and numb areas on separate hand diagrams. Patients also completed demographic, condition-related, and psychosocial (Pain Catastrophizing Scale, Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test, and Short Health Anxiety Inventory) questionnaires. Bivariate and multivariable analyses were used to determine factors associated with total area marked on the pain and numbness diagrams. Results The total area marked on the pain diagram correlated with catastrophic thinking, symptoms of depression, and health anxiety. In multivariable analysis, catastrophic thinking was the sole predictor of marked pain area, accounting for 10% of variance in the hand pain diagram. The total area marked on the numbness diagram correlated with the interval between onset and visit, diagnosis, catastrophic thinking, and symptoms of depression. In multivariable analysis, the interval between onset and visit, a diagnosis of carpal tunnel syndrome, and catastrophic thinking were independently associated with total area marked on the hand numbness diagram. Conclusions Catastrophic thinking was independently associated with larger pain and numbness areas on a hand diagram. This suggests that larger symptom markings on hand diagrams may indicate less effective coping strategies. Hand diagrams might be used as a basis for discussion of coping strategies and illness behavior in patients with upper extremity conditions. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Diagnostic III. Key words Hand diagram, psychosocial, catastrophic thinking, symptoms, pain and numbness.
From the *Department of Orthopedic Surgery, Hand and Upper Extremity Service; the †Department of Behavioral Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; and the ‡Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. Received for publication February 11, 2015; accepted in revised form July 16, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David Ring, MD, PhD, Department of Orthopedic Surgery, Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital; Yawkey Center, Suite 2100, 55 Fruit St., Boston, MA 02114; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.07.031
D
IAGRAMS IN WHICH PATIENTS MARK the areas where they experience pain are used in the diagnoses and treatment of musculoskeletal conditions.1e5 Hand diagrams in which patients mark the areas where they experience numbness, tingling, and pain are used to screen for carpal tunnel syndrome.5 The reported diagnostic performance of the hand diagrams for diagnosis of carpal tunnel syndrome is inconsistent because sensitivity ranges between 19% and 90%, and specificity between 39% and 95%.5e9 Interobserver reliability of scoring
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
ranges from slight agreement (k ¼ 0.24) to nearly perfect agreement (k ¼ 0.97).7,10,11 A simplified scoring system was proposed to improve its ease of use while maintaining similar reliability and diagnostic performance.12 The relationship between the hand diagram and clinical and neurophysiological parameters is variable, with some studies showing an association5e9,12,13 and others not.14 Because the hand diagram rating system is subjective, it may be associated with psychosocial factors. Bessette et al15 found that on a hand diagram test, larger or more extensive drawings were associated with a lower score on the mental health subscales of the Short Forme36 questionnaire. Because of the substantial evidence that coping strategies and symptoms of depression explain a large part of the variation in pain intensity and disability in patients with hand and upper extremity illness,16e27 it is possible that a higher hand diagram score is more a function of a patient’s ability to cope and psychosocial distress than of anatomic pathology. If true, this can have important clinical implications. If pain and numbness diagrams correlate with psychological distress and ineffective coping strategies, unusual diagrams could help identify patients who might benefit from screening for stress, distress, and ineffective coping strategies and consideration of psychosocial interventions. This is particularly important because psychosocial factors affect hand specific disability after surgery.26 The purpose of this study was to evaluate the relationship between ratings of pain and numbness on the hand diagram and depression, catastrophic thinking, and health anxiety. We tested the null hypotheses that, first, there was no correlation between the total area marked on a hand pain diagram (in square centimeters) and catastrophic thinking, depression, health anxiety, condition-related variables, and demographics, and second, that there was no correlation between the total area marked on a numbness diagram and catastrophic thinking, depression, health anxiety, conditionrelated variables, and demographics. This study addressed the size, not the pattern, of the marked areas on the diagram.
TABLE 1. Men
78 (50)
Women
77 (50)
Age, y (mean [SD])
53 (18)
Education, y (mean [SD])
15 (3)
Marital status, n (%) Married or with partner
92 (59)
Single
41 (26)
Separated or widowed
22 (14)
Race, n (%) White
136 (88)
Black
4 (3)
Asian
9 (6)
Other
6 (4)
Dominant side, n (%) Affected Not affected
106 (68) 49 (32)
Postoperative, n (%) Yes
17 (11)
No
138 (89)
Diagnosis, n (%) Trigger finger
22 (14)
Carpal tunnel syndrome
22 (14)
Hand fracture
16 (10)
Distal radius fracture
11 (7)
Sprain, rupture, or dislocation
10 (14)
Elbow fracture
7 (4)
Osteoarthritis
7 (4)
Tumor, lump, cyst, or nodule
7 (4)
Amputation, crush, or laceration Other
5 (3) 48 (31)
Interval between onset and visit, mo (mean [SD]) 18 (40) Type of visit, n (%) New patient
94 (61)
Follow-up patient
61 (39)
PROMIS Depression CAT score, mean (SD)
48 (10)
PCS-4 score, mean (SD)
4.8 (4)
SHAI-5 score, mean (SD)
6.3 (3)
Subjects We obtained a sample of average hand surgery patients. Inclusion criteria were patients with English fluency and literacy, age greater than 18 years, and the ability to provide informed consent. Pregnant women were excluded consistent with requirements from the institutional review board. All patients provided informed consent before any study procedures. A total of 166 patients who met the inclusion criteria
MATERIALS AND METHODS Study design In an observational cross-sectional study approved by our institutional review board, new and follow-up patients presenting to a hand surgeon were invited to participate between April 2014 and September 2014 and again during March 2015. J Hand Surg Am.
Patient Characteristics (n [ 155)
Sex, n (%)
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
3
FIGURE 1: Patient with ineffective coping strategies. A 69-year-old woman who presented with a left humerus nonunion. We considered her representation of symptoms (pain diagram) disproportionate and she had the following scores: PCS score ¼ 15, PROMIS depression score ¼ 69, and SHAI score ¼ 14.
Outcome measures To define total area marked for pain and numbness, 2 separate hand diagrams that represented arm and hand surfaces5 were marked for pain and numbness. Each diagram consists of 4 figures: ventral and dorsal views of the entire upper extremity and dorsal and volar views of the hand alone. The latter was magnified 3.3 times to help the patient mark the areas in the hand with greater detail. We quantified the marked area in square centimeters using the scale option available in computeraided design software (Rhinoceros, McNeel, Seattle, WA). Each patient received 2 separate total area marked scores: one for pain and the other for numbness. The abbreviated Pain Catastrophizing Scale (PCS-4) is a reliable and valid measure28 used to measure catastrophic thinking about pain, defined as misinterpretation or overinterpretation of nociception. This is a 4-item questionnaire based on the original PCS-13 questionnaire.28 Questions are answered on 5-point Likert scales (0 represents “not at all” and 4 “all the time”). The total score ranges from 0 to 16. A higher score indicates an amplified negative orientation toward pain. We used the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Computer Adaptive
were asked to participate. Ten patients declined participation. One patient did not complete the questionnaires and was excluded from analysis, which left a total of 155 patients in this study (Table 1). Study procedures Upon enrollment and consent, all patients were instructed to mark areas of pain and numbness on separate diagrams depicting hand and upper extremity in ventral and dorsal views, based on the hand diagram as described by Katz and Stirrat5 (Figs. 1, 2; Appendix A, available on the Journal’s Web site at www.jhandsurg. org). Research fellows provided assistance marking the diagrams in case patients were not able to do so independently, but this was rarely an issue. After marking the diagrams and before consulting with the surgeon, patients completed demographic (age, sex, race, education, and marital status), condition-related (diagnosis, affected side, interval between onset and visit, and history of surgery), and psychosocial questionnaires (depression, pain catastrophic thinking, and health anxiety). All data were collected through the Assessment Center (http://www.assessmentcenter.net) using tablet computers. J Hand Surg Am.
r
Vol. -, - 2015
4
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
FIGURE 2: Patient with effective coping strategies. A 66-year-old woman who presented with medial epicondylosis. We considered her representation of symptoms (pain diagram) representative. She had the following scores: PCS score ¼ 4, PROMIS depression score ¼ 45, and SHAI score ¼ 3.
10 predictors and an R2 of 0.10 (effect size, 0.11) and a ¼ .05, and we recruited 44 additional patients. Continuous variables are described using means and SD; categorical variables are presented as frequency and percentage statistics. Pain and numbness total areas marked were measured separately in square centimeters. In bivariate analyses the correlation between each of the pain and numbness total area marked and continuous variables (age, education, interval between onset and visit, PCS-4, SHAI-5, and PROMIS Depression CAT) were analyzed using Pearson correlations. Associations of total area marked with dichotomous variables were analyzed with the independent t test. Associations between total area marked and categorical variables with more than 2 categories were analyzed using the one-way analysis of variance test. Variables that satisfied the criterion for entry (P < .10 in bivariate analyses) were inserted in a stepwise, multivariable linear regression analysis to assess their ability to explain the variation in total area marked. For each model, the R2 and partial R2 were calculated; R2 is the percentage of variance in the dependent variable (ie, pain or numbness diagram area) explained by all of the variables in the model and the partial R2 is the percentage of variance in the
Test (CAT) to measure the severity of symptoms of depression29,30 using the full 28-item question bank. In CAT questionnaires, relevant items are selected based on previous responses.31 The standardized mean score of the PROMIS Depression CAT is 50 points. Higher scores indicate more symptoms of depression. The abbreviated Short Health Anxiety Inventory (SHAI-5) is a reliable and valid measure28 used to measure anxiety about health. This is a 5-item questionnaire based on the original SHAI-18 questionnaire. Each item has a score ranging from 0 to 3 with the range of total scores between 0 and 15. A higher score indicates greater health anxiety (Appendix B, available on the Journal’s Web site at www.jhandsurg.org). Statistical analysis Based on a priori power analysis, we determined that 112 patients were needed to provide 90% power to detect a medium effect size between the total area marked on the pain diagram and catastrophic thinking with a ¼ .05. However, more patients were needed to account for specific diagnoses in the multivariable linear regression analysis without overfitting of the regression model. As such, a post hoc power analyses suggested that a total sample size of 156 would provide 80% with J Hand Surg Am.
r
Vol. -, - 2015
5
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
TABLE 2.
Bivariate Analysis: Factors Associated With Pain and Numbness Diagram Area Pain Diagram Area Variable
Mean (SD)
Numbness Diagram Area
P Value
Mean (SD)
.280
Sex Male
3.0 (4.9)
Female
4.2 (9.0)
.400 2.7 (7.4) 4.4 (16.0)
.660
Marital status
.510
Married or with partner
3.3 (7.3)
4.3 (15.6)
Single
3.6 (6.4)
1.6 (3.4)
Separated or widowed
4.9 (8.4)
4.2 (8.6) .690
Race
.490
White
4.1 (8.1)
3.4 (13)
Black
1.9 (0.5)
0.1 (1.5)
Asian
1.2 (1.5)
9.5 (18.0)
Other
4.9 (6.1)
2.8 (1.2) .460
Dominant side Affected
3.9 (6.5)
Non-affected
3.0 (8.5)
.070 4.5 (15) 1.6 (4.1) < .001*
.320
Diagnosis Trigger finger
2.3 (3.8)
0.3 (0.9)
Carpal tunnel syndrome
4.5 (7.8)
19.0 (29.0)
Hand fracture
1.7 (2.2)
2.2 (4.4)
Distal radius fracture
5.5 (6.7)
2.2 (6.1)
Sprain, rupture, or dislocation
1.2 (2.2)
< 0.1 (0.1)
Elbow fracture
7.7 (4.5)
0.2 (0.5)
Osteoarthritis
7.0 (12)
0.0(0.0)
Tumor, lump, cyst, or nodule
0.7 (1.1)
0.3 (0.8)
Amputation, crush, or laceration
0.3 (0.1)
< 0.1 (< 0.1)
Other
4.2 (9.5)
1.4 (3.9) .870
Type of visit
.330
New patient
3.5 (7.7)
2.8 (10.0)
Follow-up patient
3.7 (6.5)
4.8 (16.0) .400
Postoperative
.390
Yes
6.2 (14)
1.1 (3.0)
No
3.3 (5.9)
3.9 (13.0)
Correlation
Correlation
Age Education
P Value
0.13
.110
0.05
.580
e0.07
.400
e0.07
.420
Interval between onset and visit
0.04
.620
0.30
< .001*
PROMIS depression score
0.29
< .001*
0.22
.006*
PCS-4 score
0.32
< .001*
0.26
.001*
SHAI-5 score
0.20
.014*
0.10
.230
*Indicates statistical significance (P < .05).
J Hand Surg Am.
r
Vol. -, - 2015
6
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
TABLE 3. Multivariable Analysis: Independent Factors Associated With Pain and Numbness Diagram Area (n [ 155) R2
Model
b
Standard Error
P Value
Partial R2
95% CI
.61
0.15
< .001
0.10
0.32e0.90
< .001
0.10
Pain diagram area* PCS-4 score †
Numbness diagram area
0.33
Diagnosis 15
2.5
0.19
10e20
PCS-4 score
Carpal tunnel syndrome
.720
0.23
.002
0.063
0.27e1.2
Interval between onset and visit
.002
0.001
.001
0.065
0.001e0.004
*PROMIS Depression CAT score, PCS-4 score, and SHAI-5 score met the criterion for entry and were inserted in the model. †Interval between onset and visit, dominant side, diagnosis, PROMIS Depression CAT score, and PCS-4 score met the criterion for entry and were inserted in the model.
dependent variable explained by the respective independent variables.
but they might also help to screen patients with ineffective coping strategies and psychological distress. We found that among psychosocial factors, catastrophic thinking was the sole predictor of the size of the total area marked on pain and numbness diagrams, explaining 10% and 6% of variance, respectively. These findings suggest that catastrophic thinking influences both pain and numbness reports, but that its effect is more pronounced for pain. There are limitations to our study. First, the patient sample was heterogeneous. Because we included all patients regardless of diagnosis, the findings are less applicable to patient groups with specific hand conditions. Second, only a subset of patients experienced numbness, which affected the total numbness area distribution and as such limited the power. However, additional analysis regarding the regression model indicated that there were no model specification errors. A study enrolling patients with symptoms of numbness specifically could provide additional information. Third, this study was performed in the clinic of one hand surgeon, and the results may not generalize to other hand surgery populations. Fourth, it is possible that anatomic variation could account for some variance in the diagram areas; however, we expect this effect to be small. Finally, it was not ideal to include patients who had the area marked for them by a research assistant. The number of patients was small, but future studies should avoid this. Although symptoms of depression and health anxiety were correlated with pain total area marked, we found that catastrophic thinking had more influence on total area marked. This is consistent with the evidence that ineffective coping strategies, in particular catastrophic thinking about pain, usually explain more of the variation in symptom intensity and magnitude of disability than psychological distress.18,20,25,27,32,33
RESULTS There were no associations between demographic and condition-related variables and total area marked on the pain diagram. However, there were significant positive correlations between total area marked on the pain diagram and catastrophic thinking (r ¼ 0.32; P < .001), symptoms of depression (r ¼ 0.29; P < .001), and health anxiety (r ¼ 0.20; P ¼ .014) (Table 2). In multivariable analysis, catastrophic thinking was the sole factor associated with total area marked on the pain diagram (b ¼ .61; 95% confidence interval [CI], 0.32e0.90; P < .001) and accounted for 10% of variance in the total marked pain area (Table 3). There were no associations between demographic variables and total area marked on the numbness diagram. However, there was a significant association between total area marked on the numbness diagram and interval between onset and visit (r ¼ 0.30; P < .001), diagnosis (P < .001), symptoms of depression (r ¼ 0.22; P ¼ .006), and catastrophic thinking (r ¼ 0.26; P ¼ .001) (Table 2). In multivariable analysis, the interval between onset and visit (b ¼ .002; 95% CI, 0.001e0.004; P ¼ .001), diagnosis (carpal tunnel syndrome; b ¼ 15; 95% CI, 10e20; P < .001), and catastrophic thinking (b ¼ .72; 95% CI, 0.27e1.2; P ¼ .002) were independently associated with total area marked on the numbness diagram, together accounting for 33% of the variance. Catastrophic thinking alone accounted for 6% variance in total marked numbness area (Table 3). DISCUSSION Hand diagrams are used to diagnose discrete pathophysiology, in particular carpal tunnel syndrome,5,8,9,12 J Hand Surg Am.
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
Evidence is accumulating that disproportionate symptoms and disability—which might manifest as a greater area marked on a hand diagram–may partly reflect less effective coping strategies such as catastrophic thinking.16e27 Pain diagrams might be used as a basis for discussion of coping strategies and an introduction of the treatment option of cognitive behavioral therapy. Conversely, a diagnosis of carpal tunnel syndrome was the factor most strongly associated with increased total area marked on the numbness diagram, which reflects its utility as a diagnostic aid for carpal tunnel syndrome.5,8,9,12 It is possible that the total area or perhaps specific patterns marked on pain and numbness diagrams are indicative of disproportionate symptoms and disability for some diagnoses more than others. Future research might examine these potential differences among various diagnoses of hand conditions to determine which diagrams merit a discussion about effective coping strategies.
14. Sharma V, Wilder-Smith EP. Self-administered hand symptom diagram for carpal tunnel syndrome diagnosis. J Hand Surg Br. 2004;29(6): 571e574. 15. Bessette L, Keller R, Lew R, et al. Prognostic value of a hand symptom diagram in surgery for carpal tunnel syndrome. J Rheumatol. 1997;24(4):726e734. 16. Bot AG, Bekkers S, Herndon JH, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after proximal interphalangeal joint sprain or dislocation. Psychosomatics. 2014;55(6):595e601. 17. Bot AG, Bossen JK, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after fingertip injuries. Psychosomatics. 2014;55(4): 372e380. 18. Bot AG, Souer JS, van Dijk CN, Ring D. Association between individual DASH tasks and restricted wrist flexion and extension after volar plate fixation of a fracture of the distal radius. Hand (N Y). 2012;7(4):407e412. 19. Cho CH, Seo HJ, Bae KC, Lee KJ, Hwang I, Warner JJ. The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair. J Shoulder Elbow Surg. 2013;22(9):1160e1166. 20. Das De S, Vranceanu AM, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1):76e81. 21. Lindenhovius A, Henket M, Gilligan BP, Lozano-Calderon S, Jupiter JB, Ring D. Injection of dexamethasone versus placebo for lateral elbow pain: a prospective, double-blind, randomized clinical trial. J Hand Surg Am. 2008;33(6):909e919. 22. Niekel MC, Lindenhovius AL, Watson JB, Vranceanu AM, Ring D. Correlation of DASH and QuickDASH with measures of psychological distress. J Hand Surg Am. 2009;34(8):1499e1505. 23. Roh YH, Lee BK, Noh JH, Oh JH, Gong HS, Baek GH. Effect of depressive symptoms on perceived disability in patients with chronic shoulder pain. Arch Orthop Trauma Surg. 2012;132(9):1251e1257. 24. Roh YH, Noh JH, Oh JH, Baek GH, Gong HS. To what degree do shoulder outcome instruments reflect patients’ psychologic distress? Clin Orthop Relat Res. 2012;470(12):3470e3477. 25. Vranceanu AM, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am. 2014;96(3):e20. 26. Vranceanu AM, Jupiter JB, Mudgal CS, Ring D. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35(6):956e960. 27. Vranceanu AM, Kadzielski J, Hwang R, Ring D. A patient-specific version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire. J Hand Surg Am. 2010;35(5):824e826. 28. Bot AG, Becker SJ, van Dijk CN, Ring D, Vranceanu AM. Abbreviated psychologic questionnaires are valid in patients with hand conditions. Clin Orthop Relat Res. 2013;471(12):4037e4044. 29. Gibbons LE, Feldman BJ, Crane HM, et al. Migrating from a legacy fixed-format measure to CAT administration: calibrating the PHQ-9 to the PROMIS depression measures. Qual Life Res. 2011;20(9): 1349e1357. 30. Pilkonis PA, Choi SW, Reise SP, Stover AM, Riley WT, Cella D. Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS(R)): depression, anxiety, and anger. Assessment. 2011;18(3):263e283. 31. Fries JF, Bruce B, Cella D. The promise of PROMIS: using item response theory to improve assessment of patient-reported outcomes. Clin Exp Rheumatol. 2005;23(5 suppl 39):S53eS57. 32. Domenech J, Sanchis-Alfonso V, Espejo B. Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2295e2300. 33. Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review. Spine J. 2014;14(11):2639e2657.
REFERENCES 1. Southerst D, Stupar M, Cote P, Mior S, Stern P. The reliability of measuring pain distribution and location using body pain diagrams in patients with acute whiplash-associated disorders. J Manipulative Physiol Ther. 2013;36(7):395e402. 2. Ginzburg BM, Merskey H, Lau CL. The relationship between pain drawings and the psychological state. Pain. 1988;35(2):141e146. 3. Hildebrandt J, Franz CE, Choroba-Mehnen B, Temme M. The use of pain drawings in screening for psychological involvement in complaints of low-back pain. Spine (Phila Pa 1976). 1988;13(6):681e685. 4. Greenough CG, Fraser RD. Comparison of eight psychometric instruments in unselected patients with back pain. Spine (Phila Pa 1976). 1991;16(9):1068e1074. 5. Katz JN, Stirrat CR. A self-administered hand diagram for the diagnosis of carpal tunnel syndrome. J Hand Surg Am. 1990;15(2):360e363. 6. Katz JN, Stirrat CR, Larson MG, Fossel AH, Eaton HM, Liang MH. A self-administered hand symptom diagram for the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol. 1990;17(11):1495e1498. 7. Franzblau A, Werner RA, Albers JW, Grant CL, Olinski D, Johnston E. Workplace surveillance for carpal tunnel syndrome using hand diagrams. J Occup Rehabil. 1994;4(4):185e198. 8. Szabo RM, Slater RR Jr, Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg Am. 1999;24(4):704e714. 9. Atroshi I, Gummesson C, Johnsson R, Ornstein E. Diagnostic properties of nerve conduction tests in population-based carpal tunnel syndrome. BMC Musculoskelet Disord. 2003;4:9. 10. Dale AM, Strickland J, Symanzik J, Franzblau A, Evanoff B. Reliability of hand diagrams for the epidemiologic case definition of carpal tunnel syndrome. J Occup Rehabil. 2008;18(3):233e248. 11. Amirfeyz R, Mehendale S, Tyrrell S, Bhatia R, Leslie I, Bannister G. Katz and Stirrat hand diagram revisited. Hand Surg. 2010;15(2):71e73. 12. Calfee RP, Dale AM, Ryan D, Descatha A, Franzblau A, Evanoff B. Performance of simplified scoring systems for hand diagrams in carpal tunnel syndrome screening. J Hand Surg Am. 2012;37(1):10e17. 13. D’Arcy CA, McGee S. The rational clinical examination: does this patient have carpal tunnel syndrome? JAMA. 2000;283(23): 3110e3117.
J Hand Surg Am.
7
r
Vol. -, - 2015
7.e1
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
APPENDIX A
J Hand Surg Am.
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
APPENDIX B. PAIN CATASTROPHIZING SCALE-4 QUESTIONNAIRE [PCS-4 Instructions] Following is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week. Select only one number per question (0 ¼ not at all; 4 ¼ all the time).
7.e2
Short Health Anxiety Inventory-5 Questionnaire [SHAI- Instruction] The following 3 questions consist of a group of 4 statements. Please read each group of statements carefully and then select the one that best describes your feelings over the past 6 months. Identify the statement by checking the box next to it, ie, if you think that statement (a) is correct, check the box next to statement (a). It may be that more than one statement applies, in which case, please check any that are applicable.
__________________________________ [Question 1] When I’m in pain ... It’s terrible and I think it’s never going to get any better not at all to a slight degree to a moderate degree to a great degree all the time
__________________________________ [Question 1] Please select the statement(s) that best describe(s) your feelings over the past 6 months. I notice aches/pains less than most other people (of my age). I notice aches/pains as much as most other people (of my age). I notice aches/pains more than most other people (of my age). I am aware of aches/pains in my body all the time.
__________________________________ [Question 2] When I’m in pain ... I become afraid that the pain may get worse not at all to a slight degree to a moderate degree to a great degree all the time
__________________________________ [Question 2] Please select the statement(s) that best describe(s) your feelings over the past 6 months. As a rule I am not aware of my bodily sensations or changes. Sometimes I am aware of my bodily sensations or changes. I am often aware of my bodily sensations or changes. I am constantly aware of my bodily sensations or changes.
__________________________________ [Question 3] When I’m in pain ... I anxiously want the pain to go away not at all to a slight degree to a moderate degree to a great degree not at all
__________________________________ [Question 3] Please select the statement(s) that best describe(s) your feelings over the past 6 months. I never think I have a serious illness. I sometimes think I have a serious illness. I often think I have a serious illness. I usually think that I am seriously ill.
__________________________________ [Question 4] When I’m in pain ... I keep thinking about how badly I want the pain to stop not at all to a slight degree to a moderate degree to a great degree all the time
J Hand Surg Am.
__________________________________ [SHAI-5 Instruction_2] For the following questions, please think about what it might be like if you had a serious illness of a type that particularly concerns you (such as heart disease,
r
Vol. -, - 2015
7.e3
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
cancer, multiple sclerosis, and so on). Obviously you cannot know for sure what it would be like; so please give your best estimate of what you THINK might happen, basing your estimate on what you know about yourself and serious illness in general.
[EDDEP06] In the past 7 days I felt helpless Never Rarely Sometimes Often Always
__________________________________ [Question 4] Please give your best estimate of what you THINK might happen, basing your estimate on what you know about yourself and serious illness in general. If I had a serious illness I would still be able to enjoy things in my life quite a lot. If I had a serious illness I would still be able to enjoy things in my life a little. If I had a serious illness I would be almost completely unable to enjoy things in my life. If I had a serious illness I would be completely unable to enjoy life at all.
__________________________________ [EDDEP07] In the past 7 days I withdrew from other people Never Rarely Sometimes Often Always __________________________________
__________________________________
[EDDEP09] In the past 7 days I felt that nothing could cheer me up Never Rarely Sometimes Often Always
[Question 5] Please give your best estimate of what you THINK might happen, basing your estimate on what you know about yourself and serious illness in general. A serious illness would ruin some aspects of my life. A serious illness would ruin many aspects of my life. A serious illness would ruin almost every aspect of my life. A serious illness would ruin every aspect of my life.
__________________________________ [EDDEP14] In the past 7 days I felt that I was not as good as other people Never Rarely Sometimes Often Always
Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test Questionnaire [EDDEP04] In the past 7 days I felt worthless Never Rarely Sometimes Often Always
__________________________________ [EDDEP17] In the past 7 days I felt sad Never Rarely Sometimes Often Always
__________________________________ [EDDEP05] In the past 7 days I felt that I had nothing to look forward to Never Rarely Sometimes Often Always
__________________________________ [EDDEP19] In the past 7 days I felt that I wanted to give up on everything
__________________________________
J Hand Surg Am.
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
Never Rarely Sometimes Often Always
7.e4
Often Always __________________________________ [EDDEP28] In the past 7 days I felt lonely Never Rarely Sometimes Often Always
__________________________________ [EDDEP21] In the past 7 days I felt that I was to blame for things Never Rarely Sometimes Often Always
__________________________________ [EDDEP29] In the past 7 days I felt depressed Never Rarely Sometimes Often Always
__________________________________ [EDDEP22] In the past 7 days I felt like a failure Never Rarely Sometimes Often Always
__________________________________ [EDDEP30] In the past 7 days I had trouble making decisions Never Rarely Sometimes Often Always
__________________________________ [EDDEP23] In the past 7 days I had trouble feeling close to people Never Rarely Sometimes Often Always
__________________________________ [EDDEP31] In the past 7 days I felt discouraged about the future Never Rarely Sometimes Often Always
__________________________________ [EDDEP26] In the past 7 days I felt disappointed in myself Never Rarely Sometimes Often Always
__________________________________ [EDDEP35] In the past 7 days I found that things in my life were overwhelming Never Rarely Sometimes Often Always
__________________________________ [EDDEP27] In the past 7 days I felt that I was not needed Never Rarely Sometimes
__________________________________ J Hand Surg Am.
r
Vol. -, - 2015
7.e5
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
[EDDEP36] In the past 7 days I felt unhappy Never Rarely Sometimes Often Always
[EDDEP45] In the past 7 days I felt that nothing was interesting Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP39] In the past 7 days I felt I had no reason for living Never Rarely Sometimes Often Always
[EDDEP46] In the past 7 days I felt pessimistic Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP41] In the past 7 days I felt hopeless Never Rarely Sometimes Often Always
[EDDEP48] In the past 7 days I felt that my life was empty Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP42] In the past 7 days I felt ignored by people Never Rarely Sometimes Often Always
[EDDEP50] In the past 7 days I felt guilty Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP44] In the past 7 days I felt upset for no reason Never Rarely Sometimes Often Always
[EDDEP54] In the past 7 days I felt emotionally exhausted Never Rarely Sometimes Often Always
__________________________________
J Hand Surg Am.
__________________________________
r
Vol. -, - 2015
The Relationship Between Catastrophic Thinking and Hand Diagram Areas Ali Moradi, MD,*‡ Jos J. Mellema, MD,* Kamilcan Oflazoglu, BSc,* Aleksandr Isakov, MSc,* David Ring, MD, PhD,* Ana-Maria Vranceanu, PhD†
Purpose To evaluate the relationship between the total area marked on pain and numbness diagrams and psychosocial factors (depression, pain catastrophic thinking, and health anxiety). Methods A total of 155 patients marked painful and numb areas on separate hand diagrams. Patients also completed demographic, condition-related, and psychosocial (Pain Catastrophizing Scale, Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test, and Short Health Anxiety Inventory) questionnaires. Bivariate and multivariable analyses were used to determine factors associated with total area marked on the pain and numbness diagrams. Results The total area marked on the pain diagram correlated with catastrophic thinking, symptoms of depression, and health anxiety. In multivariable analysis, catastrophic thinking was the sole predictor of marked pain area, accounting for 10% of variance in the hand pain diagram. The total area marked on the numbness diagram correlated with the interval between onset and visit, diagnosis, catastrophic thinking, and symptoms of depression. In multivariable analysis, the interval between onset and visit, a diagnosis of carpal tunnel syndrome, and catastrophic thinking were independently associated with total area marked on the hand numbness diagram. Conclusions Catastrophic thinking was independently associated with larger pain and numbness areas on a hand diagram. This suggests that larger symptom markings on hand diagrams may indicate less effective coping strategies. Hand diagrams might be used as a basis for discussion of coping strategies and illness behavior in patients with upper extremity conditions. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Diagnostic III. Key words Hand diagram, psychosocial, catastrophic thinking, symptoms, pain and numbness.
From the *Department of Orthopedic Surgery, Hand and Upper Extremity Service; the †Department of Behavioral Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; and the ‡Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. Received for publication February 11, 2015; accepted in revised form July 16, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David Ring, MD, PhD, Department of Orthopedic Surgery, Hand and Upper Extremity Service, Harvard Medical School, Massachusetts General Hospital; Yawkey Center, Suite 2100, 55 Fruit St., Boston, MA 02114; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.07.031
D
IAGRAMS IN WHICH PATIENTS MARK the areas where they experience pain are used in the diagnoses and treatment of musculoskeletal conditions.1e5 Hand diagrams in which patients mark the areas where they experience numbness, tingling, and pain are used to screen for carpal tunnel syndrome.5 The reported diagnostic performance of the hand diagrams for diagnosis of carpal tunnel syndrome is inconsistent because sensitivity ranges between 19% and 90%, and specificity between 39% and 95%.5e9 Interobserver reliability of scoring
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
ranges from slight agreement (k ¼ 0.24) to nearly perfect agreement (k ¼ 0.97).7,10,11 A simplified scoring system was proposed to improve its ease of use while maintaining similar reliability and diagnostic performance.12 The relationship between the hand diagram and clinical and neurophysiological parameters is variable, with some studies showing an association5e9,12,13 and others not.14 Because the hand diagram rating system is subjective, it may be associated with psychosocial factors. Bessette et al15 found that on a hand diagram test, larger or more extensive drawings were associated with a lower score on the mental health subscales of the Short Forme36 questionnaire. Because of the substantial evidence that coping strategies and symptoms of depression explain a large part of the variation in pain intensity and disability in patients with hand and upper extremity illness,16e27 it is possible that a higher hand diagram score is more a function of a patient’s ability to cope and psychosocial distress than of anatomic pathology. If true, this can have important clinical implications. If pain and numbness diagrams correlate with psychological distress and ineffective coping strategies, unusual diagrams could help identify patients who might benefit from screening for stress, distress, and ineffective coping strategies and consideration of psychosocial interventions. This is particularly important because psychosocial factors affect hand specific disability after surgery.26 The purpose of this study was to evaluate the relationship between ratings of pain and numbness on the hand diagram and depression, catastrophic thinking, and health anxiety. We tested the null hypotheses that, first, there was no correlation between the total area marked on a hand pain diagram (in square centimeters) and catastrophic thinking, depression, health anxiety, condition-related variables, and demographics, and second, that there was no correlation between the total area marked on a numbness diagram and catastrophic thinking, depression, health anxiety, conditionrelated variables, and demographics. This study addressed the size, not the pattern, of the marked areas on the diagram.
TABLE 1. Men
78 (50)
Women
77 (50)
Age, y (mean [SD])
53 (18)
Education, y (mean [SD])
15 (3)
Marital status, n (%) Married or with partner
92 (59)
Single
41 (26)
Separated or widowed
22 (14)
Race, n (%) White
136 (88)
Black
4 (3)
Asian
9 (6)
Other
6 (4)
Dominant side, n (%) Affected Not affected
106 (68) 49 (32)
Postoperative, n (%) Yes
17 (11)
No
138 (89)
Diagnosis, n (%) Trigger finger
22 (14)
Carpal tunnel syndrome
22 (14)
Hand fracture
16 (10)
Distal radius fracture
11 (7)
Sprain, rupture, or dislocation
10 (14)
Elbow fracture
7 (4)
Osteoarthritis
7 (4)
Tumor, lump, cyst, or nodule
7 (4)
Amputation, crush, or laceration Other
5 (3) 48 (31)
Interval between onset and visit, mo (mean [SD]) 18 (40) Type of visit, n (%) New patient
94 (61)
Follow-up patient
61 (39)
PROMIS Depression CAT score, mean (SD)
48 (10)
PCS-4 score, mean (SD)
4.8 (4)
SHAI-5 score, mean (SD)
6.3 (3)
Subjects We obtained a sample of average hand surgery patients. Inclusion criteria were patients with English fluency and literacy, age greater than 18 years, and the ability to provide informed consent. Pregnant women were excluded consistent with requirements from the institutional review board. All patients provided informed consent before any study procedures. A total of 166 patients who met the inclusion criteria
MATERIALS AND METHODS Study design In an observational cross-sectional study approved by our institutional review board, new and follow-up patients presenting to a hand surgeon were invited to participate between April 2014 and September 2014 and again during March 2015. J Hand Surg Am.
Patient Characteristics (n [ 155)
Sex, n (%)
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
3
FIGURE 1: Patient with ineffective coping strategies. A 69-year-old woman who presented with a left humerus nonunion. We considered her representation of symptoms (pain diagram) disproportionate and she had the following scores: PCS score ¼ 15, PROMIS depression score ¼ 69, and SHAI score ¼ 14.
Outcome measures To define total area marked for pain and numbness, 2 separate hand diagrams that represented arm and hand surfaces5 were marked for pain and numbness. Each diagram consists of 4 figures: ventral and dorsal views of the entire upper extremity and dorsal and volar views of the hand alone. The latter was magnified 3.3 times to help the patient mark the areas in the hand with greater detail. We quantified the marked area in square centimeters using the scale option available in computeraided design software (Rhinoceros, McNeel, Seattle, WA). Each patient received 2 separate total area marked scores: one for pain and the other for numbness. The abbreviated Pain Catastrophizing Scale (PCS-4) is a reliable and valid measure28 used to measure catastrophic thinking about pain, defined as misinterpretation or overinterpretation of nociception. This is a 4-item questionnaire based on the original PCS-13 questionnaire.28 Questions are answered on 5-point Likert scales (0 represents “not at all” and 4 “all the time”). The total score ranges from 0 to 16. A higher score indicates an amplified negative orientation toward pain. We used the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Computer Adaptive
were asked to participate. Ten patients declined participation. One patient did not complete the questionnaires and was excluded from analysis, which left a total of 155 patients in this study (Table 1). Study procedures Upon enrollment and consent, all patients were instructed to mark areas of pain and numbness on separate diagrams depicting hand and upper extremity in ventral and dorsal views, based on the hand diagram as described by Katz and Stirrat5 (Figs. 1, 2; Appendix A, available on the Journal’s Web site at www.jhandsurg. org). Research fellows provided assistance marking the diagrams in case patients were not able to do so independently, but this was rarely an issue. After marking the diagrams and before consulting with the surgeon, patients completed demographic (age, sex, race, education, and marital status), condition-related (diagnosis, affected side, interval between onset and visit, and history of surgery), and psychosocial questionnaires (depression, pain catastrophic thinking, and health anxiety). All data were collected through the Assessment Center (http://www.assessmentcenter.net) using tablet computers. J Hand Surg Am.
r
Vol. -, - 2015
4
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
FIGURE 2: Patient with effective coping strategies. A 66-year-old woman who presented with medial epicondylosis. We considered her representation of symptoms (pain diagram) representative. She had the following scores: PCS score ¼ 4, PROMIS depression score ¼ 45, and SHAI score ¼ 3.
10 predictors and an R2 of 0.10 (effect size, 0.11) and a ¼ .05, and we recruited 44 additional patients. Continuous variables are described using means and SD; categorical variables are presented as frequency and percentage statistics. Pain and numbness total areas marked were measured separately in square centimeters. In bivariate analyses the correlation between each of the pain and numbness total area marked and continuous variables (age, education, interval between onset and visit, PCS-4, SHAI-5, and PROMIS Depression CAT) were analyzed using Pearson correlations. Associations of total area marked with dichotomous variables were analyzed with the independent t test. Associations between total area marked and categorical variables with more than 2 categories were analyzed using the one-way analysis of variance test. Variables that satisfied the criterion for entry (P < .10 in bivariate analyses) were inserted in a stepwise, multivariable linear regression analysis to assess their ability to explain the variation in total area marked. For each model, the R2 and partial R2 were calculated; R2 is the percentage of variance in the dependent variable (ie, pain or numbness diagram area) explained by all of the variables in the model and the partial R2 is the percentage of variance in the
Test (CAT) to measure the severity of symptoms of depression29,30 using the full 28-item question bank. In CAT questionnaires, relevant items are selected based on previous responses.31 The standardized mean score of the PROMIS Depression CAT is 50 points. Higher scores indicate more symptoms of depression. The abbreviated Short Health Anxiety Inventory (SHAI-5) is a reliable and valid measure28 used to measure anxiety about health. This is a 5-item questionnaire based on the original SHAI-18 questionnaire. Each item has a score ranging from 0 to 3 with the range of total scores between 0 and 15. A higher score indicates greater health anxiety (Appendix B, available on the Journal’s Web site at www.jhandsurg.org). Statistical analysis Based on a priori power analysis, we determined that 112 patients were needed to provide 90% power to detect a medium effect size between the total area marked on the pain diagram and catastrophic thinking with a ¼ .05. However, more patients were needed to account for specific diagnoses in the multivariable linear regression analysis without overfitting of the regression model. As such, a post hoc power analyses suggested that a total sample size of 156 would provide 80% with J Hand Surg Am.
r
Vol. -, - 2015
5
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
TABLE 2.
Bivariate Analysis: Factors Associated With Pain and Numbness Diagram Area Pain Diagram Area Variable
Mean (SD)
Numbness Diagram Area
P Value
Mean (SD)
.280
Sex Male
3.0 (4.9)
Female
4.2 (9.0)
.400 2.7 (7.4) 4.4 (16.0)
.660
Marital status
.510
Married or with partner
3.3 (7.3)
4.3 (15.6)
Single
3.6 (6.4)
1.6 (3.4)
Separated or widowed
4.9 (8.4)
4.2 (8.6) .690
Race
.490
White
4.1 (8.1)
3.4 (13)
Black
1.9 (0.5)
0.1 (1.5)
Asian
1.2 (1.5)
9.5 (18.0)
Other
4.9 (6.1)
2.8 (1.2) .460
Dominant side Affected
3.9 (6.5)
Non-affected
3.0 (8.5)
.070 4.5 (15) 1.6 (4.1) < .001*
.320
Diagnosis Trigger finger
2.3 (3.8)
0.3 (0.9)
Carpal tunnel syndrome
4.5 (7.8)
19.0 (29.0)
Hand fracture
1.7 (2.2)
2.2 (4.4)
Distal radius fracture
5.5 (6.7)
2.2 (6.1)
Sprain, rupture, or dislocation
1.2 (2.2)
< 0.1 (0.1)
Elbow fracture
7.7 (4.5)
0.2 (0.5)
Osteoarthritis
7.0 (12)
0.0(0.0)
Tumor, lump, cyst, or nodule
0.7 (1.1)
0.3 (0.8)
Amputation, crush, or laceration
0.3 (0.1)
< 0.1 (< 0.1)
Other
4.2 (9.5)
1.4 (3.9) .870
Type of visit
.330
New patient
3.5 (7.7)
2.8 (10.0)
Follow-up patient
3.7 (6.5)
4.8 (16.0) .400
Postoperative
.390
Yes
6.2 (14)
1.1 (3.0)
No
3.3 (5.9)
3.9 (13.0)
Correlation
Correlation
Age Education
P Value
0.13
.110
0.05
.580
e0.07
.400
e0.07
.420
Interval between onset and visit
0.04
.620
0.30
< .001*
PROMIS depression score
0.29
< .001*
0.22
.006*
PCS-4 score
0.32
< .001*
0.26
.001*
SHAI-5 score
0.20
.014*
0.10
.230
*Indicates statistical significance (P < .05).
J Hand Surg Am.
r
Vol. -, - 2015
6
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
TABLE 3. Multivariable Analysis: Independent Factors Associated With Pain and Numbness Diagram Area (n [ 155) R2
Model
b
Standard Error
P Value
Partial R2
95% CI
.61
0.15
< .001
0.10
0.32e0.90
< .001
0.10
Pain diagram area* PCS-4 score †
Numbness diagram area
0.33
Diagnosis 15
2.5
0.19
10e20
PCS-4 score
Carpal tunnel syndrome
.720
0.23
.002
0.063
0.27e1.2
Interval between onset and visit
.002
0.001
.001
0.065
0.001e0.004
*PROMIS Depression CAT score, PCS-4 score, and SHAI-5 score met the criterion for entry and were inserted in the model. †Interval between onset and visit, dominant side, diagnosis, PROMIS Depression CAT score, and PCS-4 score met the criterion for entry and were inserted in the model.
dependent variable explained by the respective independent variables.
but they might also help to screen patients with ineffective coping strategies and psychological distress. We found that among psychosocial factors, catastrophic thinking was the sole predictor of the size of the total area marked on pain and numbness diagrams, explaining 10% and 6% of variance, respectively. These findings suggest that catastrophic thinking influences both pain and numbness reports, but that its effect is more pronounced for pain. There are limitations to our study. First, the patient sample was heterogeneous. Because we included all patients regardless of diagnosis, the findings are less applicable to patient groups with specific hand conditions. Second, only a subset of patients experienced numbness, which affected the total numbness area distribution and as such limited the power. However, additional analysis regarding the regression model indicated that there were no model specification errors. A study enrolling patients with symptoms of numbness specifically could provide additional information. Third, this study was performed in the clinic of one hand surgeon, and the results may not generalize to other hand surgery populations. Fourth, it is possible that anatomic variation could account for some variance in the diagram areas; however, we expect this effect to be small. Finally, it was not ideal to include patients who had the area marked for them by a research assistant. The number of patients was small, but future studies should avoid this. Although symptoms of depression and health anxiety were correlated with pain total area marked, we found that catastrophic thinking had more influence on total area marked. This is consistent with the evidence that ineffective coping strategies, in particular catastrophic thinking about pain, usually explain more of the variation in symptom intensity and magnitude of disability than psychological distress.18,20,25,27,32,33
RESULTS There were no associations between demographic and condition-related variables and total area marked on the pain diagram. However, there were significant positive correlations between total area marked on the pain diagram and catastrophic thinking (r ¼ 0.32; P < .001), symptoms of depression (r ¼ 0.29; P < .001), and health anxiety (r ¼ 0.20; P ¼ .014) (Table 2). In multivariable analysis, catastrophic thinking was the sole factor associated with total area marked on the pain diagram (b ¼ .61; 95% confidence interval [CI], 0.32e0.90; P < .001) and accounted for 10% of variance in the total marked pain area (Table 3). There were no associations between demographic variables and total area marked on the numbness diagram. However, there was a significant association between total area marked on the numbness diagram and interval between onset and visit (r ¼ 0.30; P < .001), diagnosis (P < .001), symptoms of depression (r ¼ 0.22; P ¼ .006), and catastrophic thinking (r ¼ 0.26; P ¼ .001) (Table 2). In multivariable analysis, the interval between onset and visit (b ¼ .002; 95% CI, 0.001e0.004; P ¼ .001), diagnosis (carpal tunnel syndrome; b ¼ 15; 95% CI, 10e20; P < .001), and catastrophic thinking (b ¼ .72; 95% CI, 0.27e1.2; P ¼ .002) were independently associated with total area marked on the numbness diagram, together accounting for 33% of the variance. Catastrophic thinking alone accounted for 6% variance in total marked numbness area (Table 3). DISCUSSION Hand diagrams are used to diagnose discrete pathophysiology, in particular carpal tunnel syndrome,5,8,9,12 J Hand Surg Am.
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
Evidence is accumulating that disproportionate symptoms and disability—which might manifest as a greater area marked on a hand diagram–may partly reflect less effective coping strategies such as catastrophic thinking.16e27 Pain diagrams might be used as a basis for discussion of coping strategies and an introduction of the treatment option of cognitive behavioral therapy. Conversely, a diagnosis of carpal tunnel syndrome was the factor most strongly associated with increased total area marked on the numbness diagram, which reflects its utility as a diagnostic aid for carpal tunnel syndrome.5,8,9,12 It is possible that the total area or perhaps specific patterns marked on pain and numbness diagrams are indicative of disproportionate symptoms and disability for some diagnoses more than others. Future research might examine these potential differences among various diagnoses of hand conditions to determine which diagrams merit a discussion about effective coping strategies.
14. Sharma V, Wilder-Smith EP. Self-administered hand symptom diagram for carpal tunnel syndrome diagnosis. J Hand Surg Br. 2004;29(6): 571e574. 15. Bessette L, Keller R, Lew R, et al. Prognostic value of a hand symptom diagram in surgery for carpal tunnel syndrome. J Rheumatol. 1997;24(4):726e734. 16. Bot AG, Bekkers S, Herndon JH, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after proximal interphalangeal joint sprain or dislocation. Psychosomatics. 2014;55(6):595e601. 17. Bot AG, Bossen JK, Mudgal CS, Jupiter JB, Ring D. Determinants of disability after fingertip injuries. Psychosomatics. 2014;55(4): 372e380. 18. Bot AG, Souer JS, van Dijk CN, Ring D. Association between individual DASH tasks and restricted wrist flexion and extension after volar plate fixation of a fracture of the distal radius. Hand (N Y). 2012;7(4):407e412. 19. Cho CH, Seo HJ, Bae KC, Lee KJ, Hwang I, Warner JJ. The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair. J Shoulder Elbow Surg. 2013;22(9):1160e1166. 20. Das De S, Vranceanu AM, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1):76e81. 21. Lindenhovius A, Henket M, Gilligan BP, Lozano-Calderon S, Jupiter JB, Ring D. Injection of dexamethasone versus placebo for lateral elbow pain: a prospective, double-blind, randomized clinical trial. J Hand Surg Am. 2008;33(6):909e919. 22. Niekel MC, Lindenhovius AL, Watson JB, Vranceanu AM, Ring D. Correlation of DASH and QuickDASH with measures of psychological distress. J Hand Surg Am. 2009;34(8):1499e1505. 23. Roh YH, Lee BK, Noh JH, Oh JH, Gong HS, Baek GH. Effect of depressive symptoms on perceived disability in patients with chronic shoulder pain. Arch Orthop Trauma Surg. 2012;132(9):1251e1257. 24. Roh YH, Noh JH, Oh JH, Baek GH, Gong HS. To what degree do shoulder outcome instruments reflect patients’ psychologic distress? Clin Orthop Relat Res. 2012;470(12):3470e3477. 25. Vranceanu AM, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am. 2014;96(3):e20. 26. Vranceanu AM, Jupiter JB, Mudgal CS, Ring D. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35(6):956e960. 27. Vranceanu AM, Kadzielski J, Hwang R, Ring D. A patient-specific version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire. J Hand Surg Am. 2010;35(5):824e826. 28. Bot AG, Becker SJ, van Dijk CN, Ring D, Vranceanu AM. Abbreviated psychologic questionnaires are valid in patients with hand conditions. Clin Orthop Relat Res. 2013;471(12):4037e4044. 29. Gibbons LE, Feldman BJ, Crane HM, et al. Migrating from a legacy fixed-format measure to CAT administration: calibrating the PHQ-9 to the PROMIS depression measures. Qual Life Res. 2011;20(9): 1349e1357. 30. Pilkonis PA, Choi SW, Reise SP, Stover AM, Riley WT, Cella D. Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS(R)): depression, anxiety, and anger. Assessment. 2011;18(3):263e283. 31. Fries JF, Bruce B, Cella D. The promise of PROMIS: using item response theory to improve assessment of patient-reported outcomes. Clin Exp Rheumatol. 2005;23(5 suppl 39):S53eS57. 32. Domenech J, Sanchis-Alfonso V, Espejo B. Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2295e2300. 33. Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review. Spine J. 2014;14(11):2639e2657.
REFERENCES 1. Southerst D, Stupar M, Cote P, Mior S, Stern P. The reliability of measuring pain distribution and location using body pain diagrams in patients with acute whiplash-associated disorders. J Manipulative Physiol Ther. 2013;36(7):395e402. 2. Ginzburg BM, Merskey H, Lau CL. The relationship between pain drawings and the psychological state. Pain. 1988;35(2):141e146. 3. Hildebrandt J, Franz CE, Choroba-Mehnen B, Temme M. The use of pain drawings in screening for psychological involvement in complaints of low-back pain. Spine (Phila Pa 1976). 1988;13(6):681e685. 4. Greenough CG, Fraser RD. Comparison of eight psychometric instruments in unselected patients with back pain. Spine (Phila Pa 1976). 1991;16(9):1068e1074. 5. Katz JN, Stirrat CR. A self-administered hand diagram for the diagnosis of carpal tunnel syndrome. J Hand Surg Am. 1990;15(2):360e363. 6. Katz JN, Stirrat CR, Larson MG, Fossel AH, Eaton HM, Liang MH. A self-administered hand symptom diagram for the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol. 1990;17(11):1495e1498. 7. Franzblau A, Werner RA, Albers JW, Grant CL, Olinski D, Johnston E. Workplace surveillance for carpal tunnel syndrome using hand diagrams. J Occup Rehabil. 1994;4(4):185e198. 8. Szabo RM, Slater RR Jr, Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg Am. 1999;24(4):704e714. 9. Atroshi I, Gummesson C, Johnsson R, Ornstein E. Diagnostic properties of nerve conduction tests in population-based carpal tunnel syndrome. BMC Musculoskelet Disord. 2003;4:9. 10. Dale AM, Strickland J, Symanzik J, Franzblau A, Evanoff B. Reliability of hand diagrams for the epidemiologic case definition of carpal tunnel syndrome. J Occup Rehabil. 2008;18(3):233e248. 11. Amirfeyz R, Mehendale S, Tyrrell S, Bhatia R, Leslie I, Bannister G. Katz and Stirrat hand diagram revisited. Hand Surg. 2010;15(2):71e73. 12. Calfee RP, Dale AM, Ryan D, Descatha A, Franzblau A, Evanoff B. Performance of simplified scoring systems for hand diagrams in carpal tunnel syndrome screening. J Hand Surg Am. 2012;37(1):10e17. 13. D’Arcy CA, McGee S. The rational clinical examination: does this patient have carpal tunnel syndrome? JAMA. 2000;283(23): 3110e3117.
J Hand Surg Am.
7
r
Vol. -, - 2015
7.e1
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
APPENDIX A
J Hand Surg Am.
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
APPENDIX B. PAIN CATASTROPHIZING SCALE-4 QUESTIONNAIRE [PCS-4 Instructions] Following is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week. Select only one number per question (0 ¼ not at all; 4 ¼ all the time).
7.e2
Short Health Anxiety Inventory-5 Questionnaire [SHAI- Instruction] The following 3 questions consist of a group of 4 statements. Please read each group of statements carefully and then select the one that best describes your feelings over the past 6 months. Identify the statement by checking the box next to it, ie, if you think that statement (a) is correct, check the box next to statement (a). It may be that more than one statement applies, in which case, please check any that are applicable.
__________________________________ [Question 1] When I’m in pain ... It’s terrible and I think it’s never going to get any better not at all to a slight degree to a moderate degree to a great degree all the time
__________________________________ [Question 1] Please select the statement(s) that best describe(s) your feelings over the past 6 months. I notice aches/pains less than most other people (of my age). I notice aches/pains as much as most other people (of my age). I notice aches/pains more than most other people (of my age). I am aware of aches/pains in my body all the time.
__________________________________ [Question 2] When I’m in pain ... I become afraid that the pain may get worse not at all to a slight degree to a moderate degree to a great degree all the time
__________________________________ [Question 2] Please select the statement(s) that best describe(s) your feelings over the past 6 months. As a rule I am not aware of my bodily sensations or changes. Sometimes I am aware of my bodily sensations or changes. I am often aware of my bodily sensations or changes. I am constantly aware of my bodily sensations or changes.
__________________________________ [Question 3] When I’m in pain ... I anxiously want the pain to go away not at all to a slight degree to a moderate degree to a great degree not at all
__________________________________ [Question 3] Please select the statement(s) that best describe(s) your feelings over the past 6 months. I never think I have a serious illness. I sometimes think I have a serious illness. I often think I have a serious illness. I usually think that I am seriously ill.
__________________________________ [Question 4] When I’m in pain ... I keep thinking about how badly I want the pain to stop not at all to a slight degree to a moderate degree to a great degree all the time
J Hand Surg Am.
__________________________________ [SHAI-5 Instruction_2] For the following questions, please think about what it might be like if you had a serious illness of a type that particularly concerns you (such as heart disease,
r
Vol. -, - 2015
7.e3
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
cancer, multiple sclerosis, and so on). Obviously you cannot know for sure what it would be like; so please give your best estimate of what you THINK might happen, basing your estimate on what you know about yourself and serious illness in general.
[EDDEP06] In the past 7 days I felt helpless Never Rarely Sometimes Often Always
__________________________________ [Question 4] Please give your best estimate of what you THINK might happen, basing your estimate on what you know about yourself and serious illness in general. If I had a serious illness I would still be able to enjoy things in my life quite a lot. If I had a serious illness I would still be able to enjoy things in my life a little. If I had a serious illness I would be almost completely unable to enjoy things in my life. If I had a serious illness I would be completely unable to enjoy life at all.
__________________________________ [EDDEP07] In the past 7 days I withdrew from other people Never Rarely Sometimes Often Always __________________________________
__________________________________
[EDDEP09] In the past 7 days I felt that nothing could cheer me up Never Rarely Sometimes Often Always
[Question 5] Please give your best estimate of what you THINK might happen, basing your estimate on what you know about yourself and serious illness in general. A serious illness would ruin some aspects of my life. A serious illness would ruin many aspects of my life. A serious illness would ruin almost every aspect of my life. A serious illness would ruin every aspect of my life.
__________________________________ [EDDEP14] In the past 7 days I felt that I was not as good as other people Never Rarely Sometimes Often Always
Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test Questionnaire [EDDEP04] In the past 7 days I felt worthless Never Rarely Sometimes Often Always
__________________________________ [EDDEP17] In the past 7 days I felt sad Never Rarely Sometimes Often Always
__________________________________ [EDDEP05] In the past 7 days I felt that I had nothing to look forward to Never Rarely Sometimes Often Always
__________________________________ [EDDEP19] In the past 7 days I felt that I wanted to give up on everything
__________________________________
J Hand Surg Am.
r
Vol. -, - 2015
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
Never Rarely Sometimes Often Always
7.e4
Often Always __________________________________ [EDDEP28] In the past 7 days I felt lonely Never Rarely Sometimes Often Always
__________________________________ [EDDEP21] In the past 7 days I felt that I was to blame for things Never Rarely Sometimes Often Always
__________________________________ [EDDEP29] In the past 7 days I felt depressed Never Rarely Sometimes Often Always
__________________________________ [EDDEP22] In the past 7 days I felt like a failure Never Rarely Sometimes Often Always
__________________________________ [EDDEP30] In the past 7 days I had trouble making decisions Never Rarely Sometimes Often Always
__________________________________ [EDDEP23] In the past 7 days I had trouble feeling close to people Never Rarely Sometimes Often Always
__________________________________ [EDDEP31] In the past 7 days I felt discouraged about the future Never Rarely Sometimes Often Always
__________________________________ [EDDEP26] In the past 7 days I felt disappointed in myself Never Rarely Sometimes Often Always
__________________________________ [EDDEP35] In the past 7 days I found that things in my life were overwhelming Never Rarely Sometimes Often Always
__________________________________ [EDDEP27] In the past 7 days I felt that I was not needed Never Rarely Sometimes
__________________________________ J Hand Surg Am.
r
Vol. -, - 2015
7.e5
CATASTROPHIC THINKING AND HAND DIAGRAM AREAS
[EDDEP36] In the past 7 days I felt unhappy Never Rarely Sometimes Often Always
[EDDEP45] In the past 7 days I felt that nothing was interesting Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP39] In the past 7 days I felt I had no reason for living Never Rarely Sometimes Often Always
[EDDEP46] In the past 7 days I felt pessimistic Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP41] In the past 7 days I felt hopeless Never Rarely Sometimes Often Always
[EDDEP48] In the past 7 days I felt that my life was empty Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP42] In the past 7 days I felt ignored by people Never Rarely Sometimes Often Always
[EDDEP50] In the past 7 days I felt guilty Never Rarely Sometimes Often Always
__________________________________
__________________________________
[EDDEP44] In the past 7 days I felt upset for no reason Never Rarely Sometimes Often Always
[EDDEP54] In the past 7 days I felt emotionally exhausted Never Rarely Sometimes Often Always
__________________________________
J Hand Surg Am.
__________________________________
r
Vol. -, - 2015