Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury

Abstract

Background

Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking.

Questions/purposes

(1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures?

Methods

Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made.

Results

Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138).

Conclusions

Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery.

Level of Evidence

Level III, diagnostic study.

Introduction

Catastrophic thinking, defined as protectiveness and preparation for the worst in response to nociception, is associated with finger stiffness after injury [2, 17].

Previous studies have examined the verbal signs of catastrophic thinking. In recordings of patient visits, phrases with content reflecting “I can’t…” (eg, “I can’t even lift a cup of coffee”) and those with content reflecting “It’s serious…” (eg, “I have a high threshold for pain”) correlated with greater catastrophic thinking [4]. In another study, the degree to which patients agreed with phrases such as “I’m weak,” “I’m dropping things,” and “It’s unbearable” correlated with lower levels of pain self-efficacy (confidence in ability to achieve goals despite nociception [18]. Both catastrophic thinking and pain self-efficacy are highly correlated with the Patient Reported Outcomes Measurement Information System (PROMIS) Pain Interference measure, measuring the degree to which nociception hinders ability to achieve goals. This correlation is strong enough that they might all be measuring the same underlying strategy [7].

We began to notice specific hand postures during physical examination in patients who seemed relatively protective. We wondered whether these postures were nonverbal signs of greater catastrophic thinking and lower self-efficacy. For instance, people trying to make a fist seem to flex their wrist when they are feeling like the stretch might cause harm. When stretching a stiff finger into the palm, we observed a tendency to extend the other fingers as the sore finger makes progress. What is notable about these postures is that they hinder an effective stretch. It is not possible to make a complete composite fist with one finger extended or the wrist flexed. In other words, the body seems to instinctively protect itself by interfering with the effectiveness of the stretch. These observed hand postures seem to be a nonverbal expression of protectiveness (catastrophic thinking and kinesophobia). People caring for those who are recovering from an injury or surgery can learn to recognize the verbal and nonverbal signs of less effective coping strategies. This may be a way—in addition to screening questionnaires—to identify opportunities to enhance resiliency. Administering psychologic questionnaires risks offending patients. Awareness of and engagement with the verbal and nonverbal signs of less effective coping strategies may be beneficial. Sometimes people do not answer the questions on a questionnaire genuinely, so verbal and nonverbal signs can provide another opportunity to identify opportunities to work on resiliency. Given the strong relationship between distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) with pain intensity and magnitude of limitations [2, 8, 10, 11], it may prove helpful to identify nonverbal indicators of high-yield psychologic opportunities to facilitate recovery. Addressing these less effective coping strategies in an early stage of recovery might identify opportunities to speed recovery. To improve early recognition of these coping strategies, we evaluated if protective hand postures are associated with psychologic factors.

Therefore, we asked: (1) Do patients with specific hand postures during physical examination score higher on questionnaires assessing pain interference, limitations, symptoms of depression, catastrophic thinking, and kinesophobia? (2) Do greater numbers of hand postures correlate with limitations or psychologic factors?

Patients and Methods

After institutional review board approval by our Human Research Committee, we performed a cross-sectional, observational study. During regular outpatient visits to our upper extremity clinic within a tertiary care hospital in the northeastern United States, we approached patients to voluntarily participate in this study. Inclusion criteria were adult patients with stiff or painful fingers after a finger, hand, or wrist injury. Research assistants identified potential subjects on the list of the day’s patients. Then the research assistant joined the surgeon for the visit and the surgeon confirmed inclusion or exclusion. From October 2014 until September 2016, we invited 156 patients to participate. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of this possible hand posture, leaving 149 patients for analysis.

Measurements

Our main explanatory variable was the presence or absence of specific hand postures during the physical examination (Table 1; Fig. 1). During this examination, the patient was asked to make a fist with the injured side and subsequently the hand movements were observed by both the physician and the researcher. All participating physicians and researchers were trained in diagnosing the specific hand postures. Physicians and researchers were provided with a detailed description of possible hand postures that could be observed. All hand postures were demonstrated to study staff and the first three patients were scored for absence or presence of a hand posture with an experienced member of the study staff present in the room. In general, scoring hand postures is easy to learn and most can be observed clearly. When uncertainty of the presence of a hand posture existed or when the physician and researcher did not agree on scoring the hand postures, a video of the physical examination was recorded and a group decision was made. We also recorded the total number of hand postures for each patient. We did not blind observers to the interview and affect of the patient. We also did not test the reliability of the diagnosis of these hand postures.

Table 1.

Description of specific hand postures among 55 patients (n = 81)

Fig. 1 A-G.

This figure shows the seven specific hand postures: (A) detachment: presenting the hand as if it is detached; (B) uninjured fingers extend as the stiff/painful finger is flexed; (C) uses opposite hand to move the injured finger when asked to demonstrate motor strength; (D) wrist flexion during attempted finger flexion; (E) thumb obstructs the path of finger flexion; (F) avoiding use of uninjured fingers; and (G) avoiding all flexion of the stiff/painful finger.

All patients were asked to complete the following validated and widely used questionnaires by a researcher (SCW, JL, CAB) not involved in patient care: (1) a sociodemographic survey; (2) the PROMIS Pain Interference computer adaptive test (CAT) assessing self-reported consequences of pain on relevant aspects of patients’ daily life; (3) PROMIS Upper Extremity Physical Function CAT assessing physical limitations; (4) PROMIS Depression CAT assessing depression; (5) the Abbreviated Pain Catastrophizing Scale (PCS-4) assessing protectiveness and irrationally preparing for the worst; and (6) the Tampa Scale of Kinesophobia (TSK) assessing fear of movement as a result of injury. The physician provided the diagnosis.

Patients completed three validated PROMIS CATs [1, 5, 12]. The overall score of each PROMIS CAT questionnaire ranges from 0 to 100; a score of 50 corresponds with the mean for the US general population. The PROMIS Pain Interference questionnaire evaluates the negative effects of pain on common social, cognitive, emotional, physical, and recreational aspects of daily life with higher scores indicating a higher degree of pain interference [1]. The PROMIS Upper Extremity Function questionnaire assesses a patient’s ability to accomplish physical activities using the upper extremity with lower scores indicating greater limitations of the upper extremity. The PROMIS Depression questionnaire evaluates severity of symptoms of depression with higher scores indicating greater symptoms of depression [12, 15].

The abbreviated PCS-4 consists of four questions of the original 13-item PCS (PCS-13) of which validity was previously established [3]. The full-length questionnaire contains 13 questions assessing three domains—helplessness, magnification, and rumination—and quantifies catastrophic thinking in patients. Based on a 4-point Likert scale, the total score can range from 0 to 52. A higher score indicates greater misinterpretation of pain perception, leading to catastrophizing of pain [15].

The TSK questionnaire contains 17 questions to assess the fear of avoidance, the fear of movement, and the fear of work-related activities, resulting from the feeling of vulnerability to painful (re)injury [6, 19]. This validated and reliable psychometric questionnaire [9] uses a 4-point Likert scale with a total score ranging from 17 to 68. A score of 37 or higher is considered a high degree of kinesophobia [19].

The following sociodemographic variables were collected: gender, age, education, race, work status, marital status, smoking status, if it was their first visit with the hand surgeon, whether the patient received any prior treatment for their injury, and if the patient experienced other pain disorders. Final diagnosis from the patient’s medical record was categorized as finger fracture, metacarpal fracture, wrist fracture, finger sprain finger, laceration, mallet fracture, carpal bone fracture, or wrist sprain.

Sample Size Calculation

An a priori sample size calculation showed that 146 patients provided 80% power to detect a difference in effect of the PROMIS Pain Interference questionnaire on patients with or without a hand posture in a multivariable logistic regression analysis model (R² 0.3) with a moderate effect size of 0.5 with α set at 0.05. To account for possible missing data or need for additional exclusion of patients, we enrolled 150 patients and analyzed 149 patients.

Statistical Analysis

A potential association of all patient-reported outcome measurement scores and other explanatory variables with our dichotomous variable presence or absence of a hand posture was assessed using an unpaired Student’s t-test, Mann-Whitney U-test, or the two-sided Fisher’s exact test based on variable type and distribution.

For our second aim regarding correlation between numbers of specific hand postures (ordinal explanatory variable) and the previously mentioned measures, bivariate analysis was also performed. An association of each explanatory variable was assessed using Spearman correlation, Mann-Whitney U test, or the Kruskal-Wallis based on variable type and distribution.

Continuous data were tested for their normality using the Shapiro-Wilk test and presented as mean with SD and median with interquartile range (IQR). When assessing the association between two continuous variables, the correlation was reported. Dichotomous and categorical data were presented as frequencies with percentages.

A two-tailed p value of < 0.05 was considered significant for all tests.

Patient Characteristics

Our study population consisted of 74 men (47%) and 76 women with a median (IQR) age of 46 (28-61) years. Most patients were white (81%), worked full-time (53%), and had a fracture of the finger, hand, or wrist (75%). Of the 149 patients, 55 patients (37%) had a hand posture. A total of seven different hand postures were observed, of which “wrist flexion during attempted finger flexion” was observed most often (30%) followed by “uninjured fingers extend as stiff/painful finger is flexed” (17%) and “avoiding use of uninjured fingers” (17%). Among the 55 patients with a hand posture, 35 patients (64%) had one hand posture, 15 patients had two (27%), four had three (7%), and one (2%) had four hand postures.

Results

Patients with one or more specific hand postures (Table 2) did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Upper Extremity Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [7-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). The PCS and TSK are highly correlated and at high risk of colinearity, so we did not perform a multivariable logistic regression analysis.

Table 2.

Bivariate analysis: hand posture and patient questionnaire scores (n = 149)

Greater catastrophic thinking was associated with a greater number of hand postures on average (rho: 0.20, p = 0.0138; Table 3). Because there was only one associated factor, we did not perform an ordinal logistic regression analysis.

Table 3.

Bivariate analysis: number of hand postures 0 to 4 (n = 149)

Discussion

Prior research showed that catastrophic thinking is associated with greater pain intensity and greater magnitude of limitations and correlates with greater finger stiffness [2, 17]. Verbal indicators of catastrophic thinking such as “I can’t…,” “It’s serious…,” and “I’m weak” are described [4, 18] and can help clinicians identify opportunities to improve health by developing more effective coping strategies. In practice, we noticed some nonverbal cues we thought might be associated with catastrophic thinking, but did not find any studies that tried to characterize these. We therefore studied if patients with a hand posture during physical examination scored higher on questionnaires assessing pain interference, symptoms of depression, limitations, catastrophic thinking, and kinesophobia. In addition, we studied if these patient-reported outcome measurements correlated with the number of observed hand postures. We found that patients with a hand posture did not score higher on the PROMIS Pain Interference, PROMIS Upper Extremity, and PROMIS Depression. However, we did find a higher degree of catastrophic thinking and kinesophobia among patients with at least one hand posture. Patients with greater catastrophic thinking had a higher total number of hand postures on average.

There were a few limitations to this study. First, the assessment of the presence of a hand posture is somewhat subjective and we did not test reliability. However, all physicians and researchers were trained to diagnose specific hand postures. Most hand postures are easy to diagnose and likely reliable; however, we did not formally test the reliability of diagnosis of a hand posture. Some postures can be subtle and if there was any systematic bias, we suspect it was that the postures were present more often than the study staff recognized or recorded, which would create a stronger association than we noted. Second, both assessors listened to the patient describe the problem and were at least partially aware of any associated distress, which could have biased the scoring. On the other hand, two assessors were present in the room and diagnosed the hand postures. Furthermore, when the physician and researcher did not agree on the scoring or when uncertainty of a hand posture existed, video material was collected and a group decision was made. Third, we included patients who presented with a variety of different injuries of the hand and upper extremity. The results might have been different if we only included patients with one specific type of traumatic injury. However, our approach could be considered a strength because it represents the common spectrum of painful/stiff finger-related injuries in a hand surgery office. Third, patients were treated by different physicians, which may have influenced both the attempts at moving and stretching and response to coaching. The utilization of hand therapy varied among physicians as well. Fourth, the finding of an association between catastrophic thinking and presence of a hand posture was a secondary study question and needs to be confirmed in a study with this as the primary study question.

Protective hand postures were associated with greater catastrophic thinking and greater kinesophobia, but not with greater pain interference, symptoms of depression, or upper extremity-specific limitations. The lack of association between PROMIS Pain Interference and protective hand postures is surprising given the high correlation of pain interference with catastrophic thinking [7]. Cognitive factors account for approximately half of the variation of interference in daily activities mediated by pain [16]. Perhaps pain interference may be partly a measure of limitations and partly a measure of coping strategies, and direct measures of coping strategies may be preferable. The association of catastrophic thinking with protective hand postures is consistent with the findings of Teunis et al. [17] that catastrophic thinking is a major determinant of finger stiffness after distal radius fracture surgery. Roh et al. [13] found that preoperative catastrophic thinking was associated with delayed recovery of strength, motion, and disability after surgery for fracture of the distal radius. Another study showed that catastrophic thinking also delayed recovery among patients with hand fractures, particularly in the first 3 months after injury [14]. Nonverbal signs of catastrophic thinking such as protective hand postures can prompt clinicians to guide patients toward more effective coping strategies to facilitate recovery.

Patients with more hand postures have greater catastrophic thinking. The combined findings that any single protective hand posture is associated with catastrophic thinking and that a greater number of postures indicates greater catastrophic thinking indicates a response curve that clinicians can use to be aware of the potential level of catastrophic thinking. We are not aware of prior studies of protective hand postures, but this association makes sense. Just as humans withdraw from pain in an attempt to limit damage (eg, a hot pan or stove), if painful finger motion seems harmful, humans assume postures that hinder or “protect” themselves from those movements. For instance, flexing the wrist or extending noninjured fingers both hinder attempted flexion of the injured finger.

The combined evidence of verbal (prior research) and nonverbal (this study) signs of less effective coping strategies provides clinicians the means to identify less effective coping strategies other than questionnaire administration. Most clinicians have not yet implemented routine administration of measures of coping strategies. Among those that have, the measures may not be immediately scored or available at the point of care. In addition, some patients are uncomfortable with the implications of psychologic questionnaires and may not answer them honestly. Awareness and recognition of the verbal and nonverbal signs of less effective coping strategies can be a timely reminder to foster optimal thoughts, emotions, and behaviors to ease and speed the recovery process. Patients with slow progress, limited response to support and education, and one or more protective hand postures might benefit from specific treatments based on cognitive-behavioral therapy and its derivatives.