What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review

Abstract

Background: Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.

Questions/purposes: (1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients' upper extremity injuries?

Methods: We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the "upper extremity", "outcome measurement", and "impairment, psychological, social or symptomatic" variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.

Results: Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.

Conclusions: Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.

Level of evidence: Level IV, therapeutic study.

Fig. 1 A-B

(A) A schematic is shown of the WHO ICF framework including ICF components and their definitions. ^*The activity and participation domains are organized into subdomains including: Learning and applying knowledge; General tasks and demands; Communication; Mobility; Self-care; Domestic life; Interpersonal international and relationships; Major life areas; Community, social and civic life. ^†The environmental domain is organized into subdomains including: Products and technology; Natural environment and human made changes to environment; Support and relationships; Attitudes; Services; Systems; Policies. ^‡The personal domain is organized into subdomains including: Sex; Age; Race; Lifestyle habits; Coping styles; Social backgrounds; Education; Overall behavior patterns; Psychological assets. Adapted from: World Health Organization (Geneva) 2013. World Health Organization. How to use the ICF: A Practical Manual for Using the International Classification of Functioning. Available at: http://www.who.int/classifications/icf/en/. Accessed October 11, 2017. (B) Examples of the WHO ICF framework that was adapted to two different types of individual with a proximal humerus fracture. The examples include some features within each domain and are not intended to represent a complete overview of all subdomains. The direction of the arrows may differ depending on specific situations. Bidirectional arrows represent a two-way influence of one domain (or subdomain) on another.

Fig. 2 A-B

(A) A flowchart demonstrates the number of articles selected during the stages of identification, screening, eligibility, and inclusion following a search period from January 1, 1996, to December 31, 2016. (B) Screening and exclusion criteria are shown.

Fig. 3

The distribution of PROMs used in the final inclusion study set is shown. QuickDASH = Quick Disabilities of the Arm, Shoulder and Hand; PROMIS = Patient Reported Outcome Measurement Information System; PF = Physical Function; CAT = Computer Adaptive Test; MHQ = Michigan Hand Questionnaire; PCS = Physical Component Summary Score; UE = upper extremity; SMFA = Short Musculoskeletal Functional Assessment; EQ-5D VAS = European Quality of Life Index; VAS = visual analog scale; SST = Simple Shoulder Test.

Fig. 4

The annual percentage rate of outcome measurement categories is represented within all published orthopaedic upper extremity articles for year based on the systematic review search criteria (2000-2016).