Injury, Int. J. Care Injured 47 (2016) 2565–2569

Factors associated with pain intensity and physical limitations after lateral ankle sprains

Jan Paul Briet, MDa,*, Roderick. M. Houwert, MD, PhDb, Michiel G.J.S. Hageman, MDc, Falco Hietbrink, MD, PhDd, David C. Ring, MD, PhDe, Egbert Jan J.M. Verleisdonk, MD, PhDa

aDepartment of Surgery, Diakonessenhuis Utrecht, Bosboomstraat 1, 3582KE, Utrecht, The Netherlands bUtrecht Traumacenter, Utrecht, The Netherlands cDepartment of Orthopaedic surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, United States dDepartment of Surgery UMC Utrecht, Heidelberglaan 100, PO 85500, 3508 GA Utrecht, The Netherlands eDepartment of Surgery and Perioperative Care, New Dell Medical Center, Austin, TX, United States

A R T I C L E I N F O

Article history: Accepted 7 September 2016

Keywords: Ankle sprain Pain self-efficacy Depression Ankle

A B S T R A C T

Background: Swelling, tenderness, and ecchymosis don’t correlate with time to functional recovery in patients with a lateral ankle sprain. It is established that psychosocial factors such as symptoms of depression and low pain self-efficacy correlate with pain intensity and magnitude of limitations in patients with musculoskeletal disorders. Objective: We studied the correlation between pain self-efficacy or symptoms of depression and (1) ankle specific limitations and (2) pain intensity in patients with a lateral ankle sprain. Further we explored the correlation between estimation of sprain severity (grade) and (3) pain intensity or magnitude of ankle specific limitations. Design: Eighty-four patients with a lateral ankle sprain prospectively completed the Pain Self Efficacy Questionnaire, the Olerud Molander Ankle Score, Ordinal scale of Pain and the Patient Health Questionnaire-2 at enrollment and the Olerud Molander Ankle Score and the Ordinal scale of Pain three weeks after the injury. Factors associated with higher ankle specific limitations and symptoms were investigated in bivariable and multivariable analysis. Results: When accounting for confounding factors, greater self-efficacy (p = 0.01) and older age (p < 0.01) were significantly associated with greater ankle specific symptoms and limitations three weeks after the injury and explained 22% of the variability in ankle specific limitations and symptoms. There was no correlation between the grade of the sprain and pain intensity or ankle specific limitations or symptoms. Conclusions: Psychosocial factors (adaptiveness in response to pain in particular) explain more of the variation in symptoms and limitations after ankle sprain than the degree of pathophysiology. The influence of adaptive illness descriptions and recovery strategies based on methods for improving self- efficacy (i.e. cognitive behavioral therapy) might enhance and speed recovery from ankle injuries and merit additional investigation. Level of evidence: Level 2 prospective cohort study.

ã 2016 Elsevier Ltd. All rights reserved.

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Injury

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Introduction

Ankle sprains are a common injury accounting for approxi- mately 4% of all injuries seen in the emergency department and 30% of all sport related injuries [1]. Most injuries, approximately 85%, are lateral ankle sprains [2].

Recovery after an acute ankle sprain focuses on adequate protection of the ankle ligaments to ensure stability, decreasing

* Corresponding author. E-mail address: [email protected] (J.P. Briet).

http://dx.doi.org/10.1016/j.injury.2016.09.016 0020-1383/ã 2016 Elsevier Ltd. All rights reserved.

swelling and tenderness followed by exercises to regain motion and strength [3–5]. It is well established that short-term immobilization is beneficial regardless of severity and long-term immobilization should be avoided [4,6,7]. The ability to begin movement as early and safely as possible is beneficial to the resolution of symptoms associated with a lateral ankle sprain [7,8]. At initial presentation, it can be challenging to identify ankle sprains that might benefit from more prolonged immobilization [9,10]. Previous studies found that the severity of swelling, grade of the sprain, ecchymosis, tenderness, and instability do not correlate with time to resumption of normal activity [9].

Fig. 1. Flowchart of study timeline.

2566 J.P. Briet et al. / Injury, Int. J. Care Injured 47 (2016) 2565–2569

For many musculoskeletal injuries, psychosocial factors such as symptoms of depression and effective coping strategies (e.g. self- efficacy) explain most of the variation in pain intensity and degree of limitations [11–22]. If these relationships also apply to ankle sprains, awareness of them might help prevent unnecessary tests, immobilization, injections, or surgery. Screening for ineffective coping strategies and psychological distress could help speed recovery using interventions based on cognitive behavioral therapy [23].

The objective of this study was to evaluate whether ankle specific limitations and pain intensity correlate with psychosocial factors, such as 1) self-efficacy in response to the ability to sense potential harm and 2) symptoms of depression. Our primary null- hypothesis is that there is no correlation between ankle specific limitations three weeks after injury and pain self-efficacy or symptoms of depression at the time of enrolment in patients with an ankle sprain. Secondary hypotheses were 1) that there is no correlation between pain intensity three weeks after the injury and pain self-efficacy or symptoms of depression in patients with ankle sprains; and 2) that there is no correlation between estimation of sprain severity (grade) and pain intensity and magnitude of ankle specific limitations.

Materials and methods

Our Institutional Review Board approved this single center cross-sectional observational study. The study was described in detail and one of the treating physicians or study staff obtained informed consent. Patients were enrolled between August 2014 and October 2015. Patients were screened for eligibility and asked to consider participation one week after their ankle injury during their visit with the treating physician. All patients between 16 and 65 years of age visiting our outpatient clinic with a lateral inversion ankle sprain with adequate x rays of the ankle were eligible for inclusion. Patients were excluded when a fracture of the foot or ankle was observed or patients experiencing recurrent ankle sprains. All patients received our standard protocolled care of: Rest/Immobilization (compression bandage)/Compression/Eleva- tion (RICE) for the first few days after which patients could start weight bearing as tolerated. Patients were advised to take over the counter analgesics if necessary.

After the consult with the treating physician, including a physical examination, the patients provided demographic infor- mation and completed a questionnaire about physical function of the ankle (Olerud Molander Ankle Score (OMAS) and grade of the injury) [24], coping strategy (Pain Self Efficacy Questionnaire (PSEQ)), symptoms of depression (Patient Health questionnaire-2 (PHQ-2)) and pain intensity (ordinal scale of pain).

Three weeks after the injury, during a routine follow up check; patients completed the same questionnaires again, except the PSEQ and PHQ-2. If patients could not return to the office, they were contacted by mail, email, or telephone to complete the questionnaire (Fig. 1).

Outcome measures

The Olerud Molander Ankle Score (OMAS) is a 9 item functional ankle score designed to assess limitations in patients with ankle fractures [25]. It has also proven validity in other acute ankle injuries such as ankle sprains [26,27]. It was developed specifically as a comparative research measure to improve consistency, uniformity, and responsiveness in ankle injury research [25]. The OMAS is a valid outcome score (r = 0.70–0.82) to detect short- term improvement in ankle status in patients with acute lateral ligament injury [26,28]. The overall score is scaled to range from 0 (most severe disability) to 100 (no disability). There were seven

patients had an incomplete OMAS. Mean score imputation of the other patients was used for these missing values.

The Pain Self Efficacy Questionnaire (PSEQ) is a 10-item patient- reported outcome questionnaire to assess both the strength and generality of a patient's confidence in the ability to accomplish a particular task or behavior in their daily activities despite pain [29,30]. The questionnaire consists of 10 questions on a 7-point Likert scale ranging from 0 (“not at all confident) to 6 (“completely confident”). The total score is the sum of all individual questions and ranges from 0 to 60. The PSEQ is both reliable and valid with a test-retest reliability of r = 0.79 and internal consistency of 0.92 [29,30]. There was one missing question in the PSEQ questionnaire of one patient. We used mean score imputation of the other patients for this invalid questionnaire.

The Patient Health Questionnaire-2 (PHQ-2) is a shortened and validated version of the PHQ-9 (test-retest reliability r = 0.84) to screen for symptoms of depression. It has an excellent correlation with the original PHQ-9 (r = 0.87) [31,32]. The PHQ-2 quickly assesses the two major symptoms of depression on a 4-point Likert scale [31,33].

The ordinal scale of pain is a scale measuring pain intensity on a scale from 0 (no pain) to 10 (worst pain ever) [34].

Statistical analysis

Data analysis was performed with SPSS version 20 (IBM Corp., Armonk, NY) for Macintosh. An a priori power analysis showed that for our primary null hypothesis (that there is no correlation between ankle specific limitations at three weeks and pain self- efficacy) with a medium effect size of 0.3, and alpha = 0.05, 84 patients are needed for 80% power, based on a bivariate correlation model. Accounting for 5% loss to follow up or incomplete data, we planned to enroll 88 patients. The data was not normally distributed according to the Kolmogorov-Smirnov test, and therefor non-parametric tests were used.

Internal consistency was determined by calculating the Crohnbach’s alpha for the PSEQ. In the bivariable analysis Spearman correlation was used for continuous variables such as self-efficacy and depression The Mann-Whitney U test was used for dichotomous variables such as sex. Kruskall-Wallis was used for categorical variables such as trauma mechanism and grade of the sprain. Variables that were near significant (p < 0.10) were inserted in a backward, stepwise, multivariable linear regression analysis to explain their correlation with ankle specific limitations. In multivariable linear regression analysis only patients with complete data for all variables were included. When categorical variables were inserted in a multivariable analysis, dummy codes were generated when there were more than two categories.

J.P. Briet et al. / Injury, Int. J. Care Injured 47 (2016) 2565–2569 2567

Patient demographics

A total of 88 patients were enrolled. The median age of the included patients was 26 (IQR = 18) years old and 47 (53%) patients were men. Most patients sustained the injury through sports (n = 42, 48%) or simple inversion trauma (n = 33, 38%, Table 1). Eighty-four patients completed the follow up. One patient was included with predominantly medial tenderness, all other patients had primary inversion ankle sprains, no high or eversion ankle injuries were included.

The median score of the PSEQ at intake was 46 (IQR = 15) and the median score of the PHQ-2 was 1 (IQR = 1). The median score of the OMAS at three weeks was 59 (IQR = 24). At three weeks follow up patients had a median score for pain of 2 on a scale from 0 to 10 (Table 1). The internal consistency of the PSEQ was excellent with a Crohnbach’s alpha of a = 0.93

Results

In bivariable analysis better ankle specific symptoms and limitations (high OMAS) three weeks after injury correlated with greater self-efficacy (PSEQ) at enrollment (p = 0.017), younger age (p < 0.01), female sex (p = 0.048), and days between first visit and outpatient clinic appointment (p = 0.029, Table 2). Using multivar- iable linear regression to account for confounding factors, higher self-efficacy and younger age were significantly associated with better ankle specific symptoms and limitations (high OMAS) and explained 24% of the variability in OMAS (R-squared: 0.24, p < 0.001, Table 3).

Lower pain intensity correlated with a greater self-efficacy (p < 0.01) and younger age (p = 0.015) three weeks after the injury in a bivariable model (Table 2). No multivariable linear regression analysis was performed to identify predictors independently associated pain intensity.

The grade of the sprain did not correlate with ankle specific symptoms and limitations (p = 0.36) or pain intensity (p = 0.45) three weeks after injury.

Table 1 Basic demographic information n = 88.

sex n % male 47 53 female 41 47

work status (1 missing) employed 68 78 unemployed 19 22

sport status (2 missing) yes 71 82 no 15 17

trauma mechanism simple inversion trauma

33 38

sportsinjury 42 48 traffic 5 6 other 8 9

Median IQRa

Age 26 18 BMI (n = 75)b 24 5.1 Days to 1 st visit 7.0 2.0 Ordinal scale of pain (n = 86) 4.0 3.0 PSEQc 46 15 PHQ�2d 1.0 1.0 OMASe at 2 weeks (n = 84) 59 24 Ordinal scale of pain, 2 weeks (n = 78) 2.0 3.0

a IQR: Interquartile range. b BMI: body mass index. c PSEQ: Pain self efficacy questionnair. d PHQ: Patient Health Questionnaire. e OMAS: Olerud Molander Ankle Score.

Discussion

Given the notable influence of depression and self-efficacy on recovery from a musculoskeletal injury or surgery, treatment to optimize coping strategies might facilitate recovery [11]. The present study found that low self-efficacy was in fact best able to account for most of the variation in ankle specific symptoms and limitations and pain intensity after an ankle sprain, while the degree of pathophysiology (grade of the sprain) had no measurable influence.

This study should be considered in light of its shortcomings. The variable time between injury and enrollment might have influenced the psychology measures, although prior research suggests that these are relatively fixed traits [29,30]. The variable duration between enrollment and final evaluation might have affected the measures of pain and ankle specific symptoms and limitations. Finally, the grade of an ankle sprain is a relatively subjective and imprecise measure of the severity of pathophysiology.

The finding that low self-efficacy correlates with symptoms and limitations after musculoskeletal injuries is consistent with previous research [11,15,35]. Stress, distress, and ineffective coping strategies account for as much or more of the variation in symptoms and limitations than accounted for by pathophysiology [11,15,35]. The prominent influence of psychosocial aspects of human illness seem underappreciated and undertreated in the care of musculoskeletal injury and illness. This may represent a missed opportunity for enhanced and more rapid recovery [15,35]. The caring connection established in the first few minutes of an office visit can help to build patient’ satisfaction. The quality of the doctor-patient interaction is more important than the minutes the office visit lasted. Therefor a physicians’ success depends significantly on its communication skills [36]. There is evidence that optimal communication strategies—empathy in particular— combined with explanations and management strategies that account for the thoughts and emotions experienced by people recovering from an injury can limit symptoms and limitations [37,38]. A preliminary study in patients with acute musculoskeletal injuries and at risk for chronic pain showed that short sessions of cognitive behavioral therapy and relaxation response strategies are associated with a decrease in pain when compared to patients who received standard care [39].

Prior research identified an incidence of estimated clinical depression between 4 and 28% in orthopaedic outpatients [40,41]. Our study only had two (2%) patients that met the threshold for an estimated diagnosis of clinical depression using the PHQ-2 [31]. Differences might be explained by the country and the younger, mostly athletic, population where the evaluation took place, as incidences may differ. Mindset and circumstances influence recovery on a continuum and merit attention at all times, not just when certain thresholds are reached. This study found a standardized effect size of r2 = 0.24 which could be described as a weak correlation. Effect sizes in psychological research such as r2

are underestimates of the true proportions of variance accounted for by the variables. This should be thought of as the lower bound of the true effect size and variance [42,43].

Our finding that the grade of the injury is not correlated with more ankle specific symptoms and limitations is in line with recent studies that state that severity of the initial ankle sprain does not necessarily predict the likelihood of developing chronic ankle instability and complaints [44].

Conclusion

For patients with an ankle sprain our study found that greater self-efficacy and younger age are associated with fewer symptoms and limitations during recovery, but the severity of the sprain is

Table 2 Bivariable correlation n = 84.

Olerud Molander Ankle score 2 weeks Ordinal scale of pain at two weeks

Mann-Whitney U Mean Z p Mean Z p

Sex Male 55 �2.0 0.048 2.6 �0.10 0.92 Female 63 2.6

Work status Yes 58 �1.0 0.31 2.6 �1.4 0.17

No 63 2.4 Sports (Y/N)

Yes 60 �0.33 0.74 2.4 �1.3 0.17 No 59 3.1

Spearman rho r p r p

Age �0.43 < 0.01 0.27 0.015 BMI 0.036 0.77 0.10 0.42 Days to 1st visit �0.24 0.029 0.16 0.11

PHQ-2 0.047 0.67 0.12 0.29 PSEQ intake 0.26 0.017 �0.32 <0.01 circumference ankle �0.11 0.28 �0.11 0.35

Kruskal-Wallis Mean H p Mean H p

trauma mechanism simple inversion 56 2.2 0.54 2.9 2.8 0.43 sport 62 2.2 traffic 54 3.6 Other 60 3.4

Grade of sprain 1 61 1.6 0.45 2.8 0.76 0.68 2 55 2.3 3 55 2.0

PHQ-2 = 2-question version of the Patient Health Questionnaire; PSEQ = Pain Self-Efficacy Questionnaire, OMAS = Olerud Molander Ankle Score.

Table 3 Linear regression for predicting ankle specific disability.a

Variable Coef. p-value 95% CI Prob > F R-Square

Lower Upper

PSEQb 0.35 0.017 0.06 0.63 <0.01 0.24 Age �0.47 <0.01 �0.77 �0.16 Sex 6.7 0.054 �0.11 14 Days to outpatient visit �0.95 0.26 �2.6 0.72

a Assessed with the Olerud Molander Ankle score two weeks after enrollment. b Pain self efficacy questionnaire.

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not. Simple tools to assess coping strategies are widely available and easy to use in clinical practice [45,46]. Guidance in the recovery period should encourage optimal self-efficacy and encourage the patient to take an active role in their recovery. Also assessment of a patient’s view of their care, treatment and outcome could be valuable for physicians’ education.

Conflict of interest

All other authors declare no conflict of interest.

Authors statement

J.P. Briet is supported by a research grant from the Cornelis Visser Foundation for this study.

M.G. Hageman is supported by Dutch research grants from arti- Keunig Eckhart Stichting and Anna Foundation. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. M.G. Hageman is also affiliated to PATIENT+ foundation, creating decision aids. No

benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

D.C. Ring reports grants from Skeletal ynamics, other from Wright Medical, personal fees from Biomet, personal fees from Acumed, other from Illuminos, personal fees from Deputy Editor for Journal of Hand Surgery, personal fees from eputy Editor for Clinical Orthopaedics and Related Research, personal fees from Universities and Hosptials, personal fees from Lawyers, outside the submitted work.

Acknowledgement

This study was supported by the Cornelis Visser Foundation. We would like to thank the Cast technicians form the Diakonessenhuis Utrecht and Zeist for their support and assistance in conducting this study.

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