Abstract
Background:
Maladaptive coping strategies can lead to less functional improvement after upper-extremity surgery. It remains uncertain how well surgeons can recognize signs of less effective coping strategies in patients in the absence of formalized questionnaires. Our purpose is to determine if the “Handshake Test” can be used to identify patients with less effective coping strategies. We hypothesize that a simple physical examination finding (a refusal or inability to shake hands) is associated with higher pain level, maladaptive coping strategies and decreased functional status.
Methods:
We prospectively analyzed 246 consecutive new patients presenting to one of three surgeons with atraumatic upper-extremity conditions. Patients completed a pain scale (NPRS) and PROMIS instruments including Self-Efficacy (SE) for Managing Symptoms, Pain Interference (PI) and Upper Extremity (UE). Each surgeon recorded a refusal to shake hands as part of a normal greeting, referred to as a “positive Handshake Test”.
Results:
200 patients (81%) patients completed all outcome measures and were included in our analysis. 8% demonstrated a positive Handshake Test. Patients with a positive Handshake Test were more likely to use tobacco; otherwise baseline demographics were similar between the two groups. Patients with a positive Handshake Test demonstrated higher pain scores (NPRS and PROMIS PI), lower levels of self-efficacy and worse self-reported functional status on the PROMIS UE.
Conclusions:
For patients with atraumatic upper-extremity conditions, those with a positive Handshake Test report higher pain levels, lower self-efficacy, and decreased self-reported functional status than patients who can perform a handshake. This simple test can aid in identifying patients with less effective coping strategies, allowing surgeons to guide patients towards interventions to improve both illness behavior and functional outcomes.
Level of Evidence: II
Keywords: coping strategies, pain catastrophizing, hand surgery, physical examination, upper-extremity surgery
Introduction
Less effective coping mechanisms, low resiliency and decreased self-efficacy are associated with poor functional outcomes after upper extremity surgery.1-2 While formal measures of coping skills can aid in identifying maladaptive coping strategies, they are not routinely administered in orthopedic clinics.3 Furthermore, it is uncertain how well physicians are able to identify verbal and nonverbal indicators of maladaptive coping strategies. Previous investigations have identified hand postures that can be associated with pain catastrophizing and kinesophobia; however, interpretation of these postures can be subjective.4
The purpose of this investigation is to determine if patients with atraumatic upper-extremity conditions who refuse to shake hands possess less effective coping strategies and functional status. We hypothesize that a simple physical examination finding, which we refer to as the “Handshake Test” can be used to identify patients with maladaptive coping strategies. This examination is performed as part of normal greeting, where the surgeon notes whether a patient is able or unable to shake hands. To our knowledge, this examination maneuver has not been previously described as an assessment coping strategies and functional status.
Methods
Institutional Review Board approval was obtained for this study. We prospectively analyzed 246 consecutive new patients 18 years of age and older who presented to one of three fellowship-trained hand and upper-extremity surgeons with an atraumatic upper-extremity complaint. All patients were seen in the outpatient clinic in a rural, academic, Level I trauma center. We excluded patients presenting with acute traumatic injuries (defined as <6 weeks from time of injury), patients with infection and those with acute ischemia. Baseline demographics were recorded for each patient. Prior to seeing the surgeon on the day of the clinic visit, each patient completed a Numeric Pain Rating Scale (NPRS) and PROMIS instruments which included the PROMIS Self-Efficacy (SE) for Managing Symptoms Short-Form 4a, PROMIS Pain Interference (PI) Short-Form 4a and the PROMIS Upper Extremity (UE) Short-Form 7a. Surgeons were blinded to the results of NPRS and PROMIS scores prior to seeing the patient. PROMIS instruments, which range from 0-100, utilize a T-score metric and higher scores indicate more of the concept being assessed. The established mean for these instruments is 50 within the general population and there is a standard deviation (SD) of 10. PROMIS SE is a validated instrument and higher PROMIS SE scores indicate higher levels of patient self-efficacy.5 In chronic musculoskeletal pain, higher levels of self-efficacy are associated with lower pain intensity and improved physical function.6
To perform the examination maneuver, each surgeon recorded a refusal to shake hands as part of a normal greeting (positive Handshake Test). Patients who were able to shake hands were considered to have a negative Handshake Test. We classified patients as having a negative Handshake Test if they made any contact with the surgeon’s hand during the handshake. A positive Handshake Test was recorded if the patient made no contact with the surgeon’s hand during the handshake or if they shook with the opposite hand. The right-handed handshake was initiated at the start of the encounter as part of a normal greeting once the surgeon entered the patient’s room. The surgeon would extend their hand to initiate the handshake, but if the patient refused to bring their hand away from their body the surgeon would not “force” the handshake. For patients with left upper-extremity complaints, a left-handed handshake was initiated at the start of the physical examination. The surgeon would tell the patient that they were going to ask them to shake hands with their left hand prior to initiating the handshake.
Descriptive statistics were used for baseline demographics. We used Student-t testing and chi-square testing to compare the means or percentages between the two groups (positive or negative Handshake Test). Since it is uncommon to perform a handshake left-handed, we performed a separate analysis of patients with complaints involving the right upper-extremity. Differences of P <0.05 were considered statistically significant.
Results
Of the 246 patients prospectively evaluated, 200 (81%) patients completed all outcome measures and were included in our analysis. Twenty of the 246 patients (8%) refused to shake hands (positive Handshake Test). Twenty percent (4/20) of the positive Handshake Tests involved the left hand. There was no statistically significant difference with respect to the rates of determining a positive Handshake Test between the three surgeons (4%, 6%, 14%; P=0.1444). Table 1 includes baseline demographics between the two groups. Patients with a positive Handshake Test were more likely have had a history of any tobacco use (70% vs 50%; P=0.0373).
Table 1.
Baseline Demographics for All Included Patients Comparing Those With a Positive and Negative Handshake Test
| (+) HANDSHAKE TEST | (-) HANDSHAKE TEST | P-VALUE | |
|---|---|---|---|
| Patients, n(%) | 20 (10%) | 180 (90%) | - |
| Age, years(SD) | 51 (14) | 55 (15) | 0.1575 |
| Male, n(%) | 8 (40%) | 80 (44%) | 0.8867 |
| Laterality right, n(%) | 16 (80%) | 110 (61%) | 0.1569 |
| Bilateral symptoms, n(%) | 2 (10%) | 40 (22%) | 0.3252 |
| Dominant arm involved, n(%) | 15 (75%) | 114 (63%) | 0.4306 |
| Tobacco use, n(%) | 14 (70%) | 77 (50%) | 0.0373 |
| Work Comp, n(%) | 1 (5%) | 5 (3%) | 0.8901 |
Table 2 includes diagnoses by anatomic region for patients in both groups. Patients with a positive Handshake Test were more likely to have a diagnosis involving the shoulder, but these results were not statistically significant (P=0.0657). For patients with a positive Handshake Test, the most common diagnoses were rotator cuff syndrome, carpal tunnel syndrome and trigger digits.
Table 2.
Distribution of Diagnoses by Anatomic Region for Patients in Both Groups
| (+) HANDSHAKE TEST | (-) HANDSHAKE TEST | |
|---|---|---|
| Total Patients, n | 20 | 180 |
| Total Diagnoses, n | 21 | 205 |
| Diagnoses per Patient | 1.05 | 1.14 |
| SHOULDER | ||
| Patients with Shoulder Diagnosis | 10 | 53 |
| % of Patients with Shoulder Diagnosis | 48% | 26% |
| Patients with: | ||
| Rotator Cuff Syndrome, n | 10 | 35 |
| Arthritis, n | 0 | 11 |
| SLAP / Biceps Pathology, n | 0 | 3 |
| Other, n | 0 | 5 |
| ELBOW | ||
| Patients with Elbow Diagnosis | 2 | 32 |
| % of Patients with Elbow Diagnosis | 9% | 16% |
| Patients with: | ||
| Cubital Tunnel Syndrome, n | 0 | 9 |
| Tendinopathy, n | 1 | 19 |
| Olecranon bursitis, n | 1 | 1 |
| Other, n | 6 | 6 |
| HAND / WRIST | ||
| Patients with Hand/Wrist Diagnosis | 9 | 103 |
| % of Patients with Hand/Wrist Diagnosis | 43% | 50% |
| Patients with: | ||
| CTS, n | 3 | 37 |
| TD, n | 2 | 20 |
| TMC arthritis, n | 1 | 13 |
| Mass, n | 0 | 9 |
| DeQuervains, n | 1 | 11 |
| Hand/Wrist Arthritis, n | 2 | 13 |
| Other, n | 0 | 13 |
Table 3 contains the NPRS scores and PROMIS scores between the two groups. Patients with a positive Handshake Test demonstrated higher NPRS scores (7.6 vs 4.8), lower PROMIS UE scores (24.5 vs 36.8), higher PROMIS PI scores (69.9 vs 59.6) and lower PROMIS SE scores (35.4 vs 44.8). All of these results were statistically significant. Table 4 includes a comparison of the NPRS scores and PROMIS scores for patients with right upper-extremity complaints.
Table 3.
Pain Scores and PROMIS Instrument Results for Patients With and Without a Positive Handshake Test
| (+) HANDSHAKE TEST | (-) HANDSHAKE TEST | P-VALUE | |
|---|---|---|---|
| NPRS Score, mean (SD) | 7.6 (2.6) | 4.8 (2.6) | <0.0001 |
| PROMIS UE, mean (SD) | 24.5 (7) | 36.8 (10) | <0.0001 |
| PROMIS PI, mean (SD) | 69.9 (8) | 59.6 (6) | <0.0001 |
| PROMIS SE, mean (SD) | 35.4 (7) | 44.8 (9) | <0.0001 |
Table 4.
Pain Scores and PROMIS Instrument Results for Patients With and Without a Positive Handshake Test That Had a Complaint Involving the Right Upper Extremity
| (+) HANDSHAKE TEST [n=16] | (-) HANDSHAKE TEST [n=110] | P-VALUE | |
|---|---|---|---|
| NPRS Score, mean (SD) | 7.0 (3) | 4.7 (3) | 0.0010 |
| PROMIS UE, mean (SD) | 25.4 (8) | 36.9 (10) | <0.0001 |
| PROMIS PI, mean (SD) | 68.9 (7) | 59.1 (9) | <0.0001 |
| PROMIS SE, mean (SD) | 35.4 (8) | 44.8 (10) | 0.0001 |
Discussion
For patients with atraumatic upper-extremity complaints, a positive Handshake Test (refusal to shake hands) is associated with higher pain intensity and worse self-reported functional status. This simple physical examination finding, which we noted in 8% of patients in our series, can be used as a reliable nonverbal indicator of less effective coping strategies. Waddell et al. helped introduce the concept of “nonorganic” physical signs in low-back pain, suggesting that patients demonstrating these five examination signs required further psychological assessment.7 However, subsequent evaluations of the “Waddell Signs” have demonstrated that while they do correlate with higher pain intensity, they do not correlate with psychological distress in patients with low back pain.8 We note that compared to patients who are able to shake hands, those with a positive Handshake Test demonstrate higher levels of pain catastrophization, lower levels of self-efficacy and worse self-reported function.
While both verbal and nonverbal patient cues can indicate maladaptive coping strategies, there is a paucity of literature analyzing the ability of hand and upper-extremity surgeons to actually recognize these cues.9-10 Medical oncologists, who deal with psychological distress on a regular basis, have difficulty recognizing distress in their patient population, demonstrating a 60% rate of disagreement.11 Furthermore, while there are a number of questionnaires available to measure coping strategies and resilience, they are infrequently administered in orthopedic clinics.3 Even in the absence of distributed questionnaires, the Handshake Test allows for surgeons to assess function, pain and illness behavior in a simplistic and objective way. This can be especially important considering that the ability of upper-extremity surgeons to recognize verbal and nonverbal indicators of maladaptive coping strategies is not well defined.
Wilkens et al. determined that protective hand postures were associated with both catastrophic thinking and kinesophobia in patients with traumatic hand and wrist injuries.4 These authors observed seven distinct hand postures associated with less-effective coping strategies. However, the physicians in the investigation had specific training for diagnosing the hand postures. The authors acknowledged the subjective nature of these assessments and did not assess the reliability of the observations. The utilization of a familiar and easily reproducible handshake greeting does not require additional training and is easy to incorporate into an examination even for patients with left-sided complaints.
There are some limitations to our study. While higher levels of pain interference and low self-efficacy (maladaptive coping strategies) are associated with psychological distress, our study did not specifically include measures of anxiety and depression. We agree with observations by previous authors, who have noted that some patients are inherently uncomfortable with the implications of psychologic assessments and thus may not provide honest answers.4 Other limitations of our study include an assessment by only three surgeons, all of whom were male. However, we did not find any statistically significant differences in the rate of positive Handshake Tests among the surgeons in our series. In addition to some of the cultures concerns regarding the use of handshakes, there is the potential for pathogen transmission related to handshakes. 12 However, since most physical examinations of the upper limb include touching the hands, some of these concerns may not be as relevant to upper-extremity surgery. Strengths of this investigation include a prospective, blinded methodology and the inclusion of multiple patient reported outcome measures.
For patients with atraumatic upper-extremity conditions, a positive Handshake Test (refusal to shake hands) is associated with high pain levels, low self-efficacy, and decreased self-reported functional status when compared to patients who can perform a handshake. This simple clinical test can aid in identifying patients with maladaptive coping strategies, allowing surgeons to guide these patients towards interventions and strategies to improve both illness behavior and functional outcomes.
References
- 1.Calderón SA, Paiva A, Ring D. Patient satisfaction after open carpal tunnel release correlates with depression. J Hand Surg. 2008;33(3):303–307. doi: 10.1016/j.jhsa.2007.11.025. [DOI] [PubMed] [Google Scholar]
- 2.Teunis T, Bot AG, Thornton ER, Ring D. Catastrophic thinking is associated with finger stiffness after distal radius fracture surgery. J Orthop Trauma. 2015;29(10):e414–420. doi: 10.1097/BOT.0000000000000342. [DOI] [PubMed] [Google Scholar]
- 3.Vranceanu AM, Beks RB, Guitton TG, Janssen SJ, Ring D. How do orthopaedic surgeons address psychological aspects of illness? Arch Bone Joint Surg. 2017;5(1):2–9. [PMC free article] [PubMed] [Google Scholar]
- 4.Wilkens SC, Lans J, Bargon CA, Ring D, Chen NC. Hand posturing is a nonverbal indicator of catastrophic thinking for finger, hand, or wrist injury. Clin Orthop Rel Res. 2018;476(4):706–713. doi: 10.1007/s11999.0000000000000089. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Gruber-Baldini AL, Velozo C, Romero S, Shulman LM. Validation of the PROMIS® measures of self-efficacy for managing chronic conditions. Quality of Life Research. 2017;26(7):1915–24. doi: 10.1007/s11136-017-1527-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Martinez-Calderon J, Zamora-Campos C, Navar-ro-Ledesma S, Luque-Suarez A. The role of self-efficacy on the prognosis of chronic musculoskeletal pain: a systematic review. J Pain. 2018;19(1):10–34. doi: 10.1016/j.jpain.2017.08.008. [DOI] [PubMed] [Google Scholar]
- 7.Waddell G, McCulloch JA, Kummel EG, Venner RM. Nonorganic physical signs in low-back pain. Spine. 1980;5(2):117–125. doi: 10.1097/00007632-198003000-00005. [DOI] [PubMed] [Google Scholar]
- 8.Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HL, Rosomoff RS. A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs. Pain Med. 2003;4(2):141–81. doi: 10.1046/j.1526-4637.2003.03015.x. [DOI] [PubMed] [Google Scholar]
- 9.Bot AG, Vranceanu AM, Herndon JH, Ring DC. Correspondence of patient word choice with psychologic factors in patients with upper extremity illness. Clin Orthop Rel Res. 2012;470(11):3180–3186. doi: 10.1007/s11999-012-2436-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Janssen SJ, Meulen DP, Nota SP, Hageman MG, Ring D. Does verbal and nonverbal communication of pain correlate with disability? Psychosomatics. 2015;56(4):338–344. doi: 10.1016/j.psym.2014.05.009. [DOI] [PubMed] [Google Scholar]
- 11.Söllner W, DeVries A, Steixner E, et al. How successful are oncologists in identifying patient distress, perceived social support, and need for psychosocial counselling? Br J Cancer. 2001;84(2):179–185. doi: 10.1054/bjoc.2000.1545. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. J Am Med Assoc. 2014;311(24):2477–2478. doi: 10.1001/jama.2014.4675. [DOI] [PubMed] [Google Scholar]