Exploring the Relationship between Pain, Psychiatric Factors, and Quality of Life in Patients with Complex Regional Pain Syndrome Type 1 after Distal Radius Fracture: An Observational, Descriptive, Cross-Sectional Study

Research Article

J Fam Med. 2024; 11(1): 1346.

Exploring the Relationship between Pain, Psychiatric Factors, and Quality of Life in Patients with Complex Regional Pain Syndrome Type 1 after Distal Radius Fracture: An Observational, Descriptive, Cross-Sectional Study

Sebastián Eustaquio Martín Pérez1,3*; Jorge Hernández Marichal1; Sergio Martínez Puente; Ignacio Suárez Solo de Zaldívar1; Isidro Miguel Martín Pérez2,3

1Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, 38300 Santa Cruz de Tenerife, Spain

2Departamento de Medicina Fisica y Farmacologia, Area de Radiologia y Medicina Fisica, Facultad de Ciencias de la Salud, Universidad de la Laguna, 38200, Santa Cruz de Tenerife, Espana

3Escuela de Doctorado y Estudios de Posgrado, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Espana

*Corresponding author: Sebastián Eustaquio Martín Pérez Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, 38300 Santa Cruz de Tenerife, Spain Email: [email protected]

Isidro Miguel Martin Perez (IMP) Departamento de Medicina Fisica y Farmacologia, Area de Radiologia y Medicina Fisica, Facultad de Ciencias de la Salud, Universidad de la Laguna, & Escuela de Doctorado y Estudios de Postgrado, Universidad de La Laguna Email: [email protected]

Received: December 20, 2023 Accepted: January 12, 2024 Published: January 20, 2024

Abstract,

Introduction: Complex Regional Pain Syndrome type 1 (CRPS-1) is defined as a group of sensory and motor disorders that occur as a result of traumatic tissue damage, such as fractures of the distal radius. Pain persistence induces supramedullary neuroplastic changes, resulting in a central sensitization syndrome, in which psychological, affective, and behavioral dimensions interact to amplify the experience of pain. The primary objective of this study was to quantify the relationship between the intensity and duration of perceived pain and psychological factors and quality of life in CS patients diagnosed with CRPS-1 after distal radius fracture.

Materials and Methods: An observational descriptive, cross-sectional study using non-probability convenience sampling was conducted from January 27, 2023 to June 11, 2023. Pain intensity, kinesiophobia, anxiety, depression, hypervigilance, catastrophizing, perceived stress, and quality of life were measured. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 20.0 (IBM Co.), which included descriptive and normality analyses and multiple correlational regression strength calculation.

Results: A total of 26 participants were selected: n=17 women (65.4%) and n=9 men (n=34.6%) with central sensitization diagnosed with CRPS-1 after distal radius fracture. Pain intensity correlated positively and strongly with kinesiophobia (TSK-11) (β=0.3697, t=2.760, p=0.014) and negatively with performance-related quality of life (β=-0.4778, t=-3.301, p=0.005). The correlation between pain duration correlated with depression was positive and very strong (β=0.7576, t=4.474, p<0.001).

Conclusion: In patients with CRPS after a distal radius fracture who have been diagnosed with CS, pain intensity has been shown to have a positive association with levels of kinesiophobia, while pain duration is significantly related to elevated levels of depression.

Keywords: Complex regional pain syndrome; Central sensitization; Fracture; Kinesiophobia; Stress; hypervigilance; Anxiety; Catastrophizing

Introduction,

Complex Regional Pain Syndrome type 1 (CRPS-1) is a group of sensory and motor disorders that occur as a result of a traumatic tissue injury such as fractures or dislocations [1-3]. Its annual incidence stands at 13.63 cases per 100,000 inhabitants, being more frequent in a ratio of 1.20 to 1 in women compared to men [4]. Although its etiology is multifactorial, it is produced by the massive release of neurotransmitters and pro-inflammatory substances from the dorsal root ganglia to the fracture region as a consequence of a dysfunction of the sympathetic Autonomic Nervous System (ANS) [5]. This excess of nociceptive information induces peripheral sensitization that leads to hyperalgesia, allodynia, impaired sweating and atrophy of the skin or joints, stiffness, etc. [6-8].

The persistence of these mechanisms triggers neuronal hyperactivity in ascending nociceptive transmission that causes not only the activation of the central Nervous System (CNS), but also of the supramedullary structures related to the ANS, causing a phenomenon called secondary or Central Sensitization (CS) [9-11] resulting in an increase in perceived pain intensity, hypersensitivity, skin redness, sweating, and a moderate loss of mobility in the affected limb.

The loss of quality of life of most of these patients is mediated, in turn, by the psychological reactions that emerge during the course of the disease, among which kinesiophobia and hypervigilance stand out [12,13], as well as the emergence of negative thoughts such as catastrophizing that feed back into aversive behavior towards pain [14-16]. In addition, in conjunction with affective disorders (e.g., depression, anxiety, etc.) [17] may act by aggravating the perception of their illness and act as predictors of poorer recovery and failure to respond to conventional treatments [18]. Recently, some imaging studies have identified the existence of alterations in neurocognitive domains in patients affected by CRPS that alter cortical areas related to learning and memory, which could explain a decrease in the coping capacity of this syndrome [19,20].

As noted above, the identification and monitoring of psychological factors, which may act as drivers of the long-term subjective pain experience, are especially important in those patients diagnosed with CRPS type 1 after a distal radius fracture since symptoms and signs compatible with CS phenomenon begin to appear in these patients. However, despite the available knowledge on how these psychological responses influence the experience and duration of CRPS, no previous descriptive study has investigated the magnitude and direction of these relationships through multiple linear regression analysis models whose analysis would allow us to understand how these psychological and quality perception factors linked to the centralized pain experienced by the patient diagnosed with CRPS interact with each other. For this reason, the main objective of this study was to quantify the relationship between the intensity and duration of perceived pain and psychological factors and quality of life in CS patients diagnosed with CRPS-1 after distal radius fracture.

Materials and Method,

Study Design,

An observational, descriptive, cross-sectional study was conducted according to the Statement for Reporting Observational Studies (STROBE) reporting standard [21] using non-probabilistic convenience sampling to quantify the association between pain intensity and psychological factors in a sample of CRPS-1 subjects with CS after radial fracture. The study was conducted from January 27 to June 11, 2023 at the European University of the Canary Islands (Campus Casa Salazar, Tenerife, Spain). Prior to inclusion in the study, each participant was required to sign written informed consent to participate and be registered in an anonymous database.

Participants,

After signing the informed consent form, the JHM investigator conducted a clinical interview to assess whether the candidates met the previously established inclusion criteria: (1) men and/or women over 18 years of age, (2) diagnosed with CRPS-1 after a radius fracture, (3) medically validated for the presence of CS-related pain using the Spanish version of the Central Sensitization Inventory (CSI) (>40) and (4) expressed their Willingness to participate by signing an informed consent form. On the other hand, the exclusion criteria were: (1) adults who suffered from cognitive impairment or psychiatric disorder and (2) who had hearing limitations or problems understanding the Spanish language.

Collection of Information and Measuring Instruments,

After evaluating the eligibility criteria and signing the informed consent to participate in the study, the ISSZ investigator collected data from March 2, 2023 to April 23, 2023 in a hospital clinic of the European University of the Canary Islands (Campus Casa Salazar, Tenerife, Spain). Information was obtained from interviews that were conducted with the aim of identifying and collecting affiliation data (e.g., sex, age, employment status, marital status, type of fracture) and anthropometric data (e.g., weight, height, BMI).

CS was then assessed using the Spanish version of the CSI, a two-part scale that assesses a total of 25 common health-related symptoms and their relationship to CS, with scores ranging from 0 (no) to 4 (always), with a maximum of 100. The instrument is reliable and valid for populations vulnerable to pain, showing high internal consistency (a=0.872) and test-retest reliability (r=0.91) [22]. Subjects who met the inclusion criteria were then administered questionnaires, scales, and assessment instruments that measured the primary variables (pain intensity and duration) and secondary variables related to psychological function (kinesiophobia, catastrophizing, anxiety, stress, depression, hypervigilance) and quality of life.

Study Variables,

Primary,

Pain intensity was assessed using the Numeric Pain Rating Scale (NPRS) [23], a validated subjective measurement instrument for acute and chronic pain that is simple to apply and frequently used to assess changes in pain intensity. It consists of a numbered line of 10 cm in which the patient indicates the level of pain, ranging from 0 (no pain) to 10 (worst pain ever perceived). On the other hand, the duration of pain was obtained by estimating the time (in months) from the medical diagnosis to the time of measurement.

Secondary,

Kinesiophobia: Kinesiophobia is the fear of movement or the fear of re-injuring oneself during movement and is considered one of the most important predictors of persistent pain. This variable was measured using the Tampa Scale for Kinesiophobia (TSK-11-SV) [24], a reliable and validated instrument consisting of 11 items that must be answered using a Likert-type scale, with the assigned range being from 1 (strongly disagree) to 4 (strongly disagree). The results of the scale are interpreted based on the final values obtained, with a higher score indicating a higher degree of kinesiophobia.

Anxiety: Anxiety is the tendency to see or react to different situations as more threatening (anxiety trait) or as a temporary period of duration and intensity characterized by tension, worry, and increased activity of the autonomic nervous system (anxiety state). In this study, anxiety was assessed with the Spanish version of the State-Trait Anxiety Inventory (STAI) [25], which measures anxiety status across 20 items with four options using a Likert-type response scale, which scores from 0 (not always) to 3 (a lot).

Perceived stress: Perceived stress is a set of psychological changes that cause various ailments in the stomach, respiratory system, skin, nervous system and/or musculoskeletal system. To evaluate this variable, the Perceived Stress Scale (PSS) [26] was used, which contains a total of 14 items with a score ranging from 0 (never) to 5 (very frequent) and which allows us to establish that the higher the score, the higher the level of perceived stress.

Depression: Depression is an affective disorder characterized by emotional irritability or loss of interest or pleasure in daily activities. This dimension was measured with the Beck Depression Inventory (BDI) [27] composed of 21 items that assess attitudes and symptoms characteristic of depression and in which participants must choose which statements best describe how they feel during the previous week, including the day the test was administered. At the end, each score must be added up, taking as a reference the score of 63 as the maximum value and 0 as the lowest.

Hypervigilance: Hypervigilance is defined as a state of alertness and signs of impending pain that occurs when threat values are high and causes the individual to engage in aversive behavior toward pain. To analyze this variable, the Pain Vigilance and Awareness Questionnaire (PVAQ) [28] was used, which assesses pain awareness, vigilance, and observation. The questionnaire consists of 9 statements, and patients must indicate their value on a scale from 0 (never) to 5 (always).

Catastrophizing: Catastrophizing measures excessively negative orientation to harmful stimuli in a painful situation. This study used the Spanish version of the Pain Catastrophizing Scale (PCS) [29] which consists of 13 statements describing pain-related emotions and thoughts, in which subjects must indicate their level of agreement with these statements on a scale of 0 (not at all) to 4 (always). Their interpretation implies that the higher the score obtained, the greater the presence of catastrophic behavior in the individual.

Quality of life: Health-related quality of life is the importance people place on their lives in the physical, mental, and social aspects that make up their health and are influenced by personal experiences, beliefs, expectations, and perceptions. To measure this variable, the Spanish version of the SF-36 Health Questionnaire was used [30]. In this tool, composed of 36 items, it evaluates different response options through a Likert-type scale, ranging from 3 to 6, so higher scores reflect a higher quality of life.

Statistical Analysis,

Statistical analysis was performed using IBM SPSS Statistics software for Windows, version 20.0 (IBM Co.), for data analysis and representation. First, the ISSZ researcher made a record in an electronic database of the results of the assessment instruments. JHM verified the accuracy of the data by completing the double data entry. Second, the SEMP researcher performed descriptive calculations to characterize the sample based on the parameters of centralization (mean and median), dispersion (standard deviation and variance) and position (first quartile and third quartile). Thirdly, the assumption of normality of each of the variables was tested using the Shapiro-Wilk test, establishing the level of statistical significance at p<0.05. If these criteria for bivariate correlations were met, Pearson's correlation coefficient was used to determine the relationship between the primary and secondary variables, as well as the coefficient of determination and alignment of each association. In the event that any of them were not met, it was decided to resort to Spearman's correlation coefficient rho to calculate the strength of association between them. The significantly associated variables were entered into independent multiple linear regression models whose result was expressed through the correlation coefficient (R), the adjusted coefficient of determination (R2-Adjust) and the mean square error (RMSE) with their corresponding result of the Snedecor F contrast test (F-value). The correlation strength of each independent variable within the regression model was described from the standardized beta coefficients (β) with its corresponding result of the T-student significance test. For its interpretation, 0.26 to 0.49 (weak) was considered; 0.50 to 0.69 (moderate); 0.70 to 0.89 (strong); and 0.90 to 1.00 (very strong). No other selection criteria were applied to include independent variables in the multiple regression model. Statistical significance was established at p<0.05.

Ethical Considerations,

All patients and controls approved in writing by assent or informed consent according to whether they were minors or adults in their voluntary participation in the study. This study was approved by the institutional ethics committee CEIm 23/171-OS_X_TFM.

Results,

Sample Description,

A total sample of 26 subjects with CRPS after a distal radius fracture who suffered from CS pain was included. A total of n=17 women (65.4%) and n=9 men (n=34.6%) aged between 47 and 79 years (mean=63.35 years, SD=8.75) were selected (Figure 1). The weight of our population ranged from 45.60 kg to 98.20 kg in the highest case (mean=78.14 kg, SD=12.65). Regarding their height, the subjects in the sample had a height that ranged from 1.64 m to 1.88 m (mean=1.74 m, SD=0.0586) obtaining a variation in Body Mass Index (BMI) from 14.39 to 30.99 kg/m2 (mean=25.92 kg / m2, SD=4.24). Regarding the type of distal radius fracture, more than half of the sample had Colles’s fracture (n=18, 69.2%), followed by Smith fracture (n=4, 15.4%) and Galeazzi and Monteggia fracture (n=4, 15.4%) (Table 1 & Figure 1).