Fear and catastrophizing thoughts aggravate risks of chronic pain after a fracture
Article Outline
The healing time of fractures is a topic of great importance for patients as well as clinicians. It has confounded many clinicians that some patients recover rapidly while others linger in the healing progress after a fracture, suffering pain and loss of functions. Apart from the physical differences of fractures that may explain the different rates of progress of healing, differences in fitness, physical body strength, gender, age, and genes may influence recovery.
It is well documented that it is beneficial for patients having elective surgery, that they get good preoperative information, explaining what the patient can expect after surgery, such as pain and discomfort, what can be done to alleviate these, possible remote complications and long-term after-effects after the operation. Such information has led to decreases in need for postoperative analgesic medication, in the length of time in hospital, as well as assisting the patient in having realistic expectations about the near future. Pain-related fear and catastrophizing thoughts in the acute phase of back pain are well documented to be associated with risks of persistent back pain and a reduction in long-term function (Morley et al., 1999, Vlaeyen et al., 2007).
Little is known about the role of fear and catastrophizing during the early phase following a fracture and of the subsequent risk of dysfunction and chronic pain. Therefore Linton et al. (Linton et al., 2010) assessed psychological factors in 70 patients within 24
h of sustaining a fracture of a wrist (n=57) or an ankle (n=13). They then followed-up the patients (56 women, 14 men; mean age 54 years) at 6 and 9 months after the fractures, exploring associations between pain, fear, and catastrophizing. Included in the follow-up were self-rated recoveries, mobility, persistent pain, and the strength of handgrip or heel-rise measures. The results indicated that fear-avoidance beliefs and catastrophizing on average were low initially, and more than 2/3 of patients initially expected full recovery within 6 months. However, less than 1/3 of the patients were fully recovered by 9 months. Those patients who had high or increasing levels of fear-avoidance beliefs had a 3-fold increased risk of more persistent pain and a 6-fold increased risk for less than full recovery of grip or heel-rise strength.
These results clearly support the fear-avoidance model which has been thoroughly documented to be important in more complex back pain conditions (Vlaeyen and Morley, 2005). Steven Linton's research group in Örebro, Sweden, have in this well designed study documented that such psychological phenomena also are associated with prolonged and painful recovery after wrist and ankle fractures. Wrist fractures and ankle fractures account for 20% and 10% of all fractures, respectively. Delayed and painful recovery is common; up to 70% have pain and have not regained pre-fracture levels of physical function 1 year after an ankle fracture (Ponzer et al., 1999). Butler (Butler, 2001) documented in an elegant study that immobilization alone, without tissue injury, causes discomfort and abnormal and painful sensations. When immobilization, which is always required for a period after a fracture, is accompanied with hypersensitivity of the central nervous system caused by the tissue injury and aggravated by detrimental psychological factors, the risk for long-lasting pain and delayed recovery of function may be high. Steven Linton's research group have documented that this is the case: Fear-avoidance is causing the patient to avoid movement for fear of pain and dysfunction of his hand or foot.
We support their conclusions, and we emphasize that this study should make all health care providers, surgeons in particular, aware of the importance of taking psychological factors into consideration early in the recovery process after fractures, even the relatively minor, but very common fractures of the wrist and ankle. Fixation and immobilization in a cast are necessary medical treatments of fractures, but they are only a part in the often prolonged recovery process after such injuries.
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PII: S1877-8860(09)00008-1
doi:10.1016/j.sjpain.2009.09.007
© 2009 Scandinavian Association for the Study of Pain. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Pain-related fear, catastrophizing and pain in the recovery from a fracture
