Mental Health Phenotypes and Patient-Reported Outcomes in Upper-Extremity Care   

Pain is a remarkable and, at times, poorly understood concept. There has been extensive research showing that patients with the same conditions can experience pain differently and that pain and activity intolerance simply can’t be explained by biomedical factors alone. We have all seen examples in our own clinics as surgeons, how 2 individuals with the same pathology and treatment can have different perceived outcomes.

In the current issue of JBJS, Miner et al. explore this very topic in a prospective, cross-sectional study in which they used cluster analysis to identify mental health phenotypes (combinations of various types of misconceptions—unhelpful thoughts or cognitive biases—and symptoms of anxiety or depression) that could potentially help to direct care. A total of 137 adult patients seeking upper-extremity musculoskeletal care completed a survey that included demographics and mental health questionnaires (3 regarding unhealthy thoughts about pain and 2 addressing psychological distress) along with measures of upper-extremity-specific activity tolerance, pain intensity, and pain self-efficacy.

Through a clustering algorithm, 4 mental health phenotypes were identified in the study population:

• Low misconceptions, low distress (77 patients)
• Notable misconceptions (36 patients)
• Notable depression and notable misconceptions (19 patients)
• Notable anxiety, depression, and misconceptions (5 patients)

The authors observed significant differences in activity tolerance, pain intensity, and pain self-efficacy based on mental health phenotype. Specifically, patients with low misconceptions and low distress had significantly greater activity tolerance and pain self-efficacy than those with notable misconceptions, notable symptoms of depression, and notable psychological distress. Patients with low misconceptions and low distress also had significantly lower pain intensity than those with notable symptoms of depression and notable symptoms of anxiety.

The authors did not find an association between phenotypes and socioeconomic status, as measured by participants’ zip code (used to calculate the home area deprivation index). In addition, they found no difference between phenotypes in terms of discrete traumatic conditions (35% of patients), discrete nontraumatic conditions (47%), and nonspecific diagnoses (18%), although they caution that they may not have had enough balance to detect differences based on diagnostic category.

As surgeons, we must consider psychological factors when counseling our patients. As the authors note, “musculoskeletal specialty and pre-specialty care units can benefit from strategies that anticipate mental and social-health opportunities.” As we increase our understanding of the interplay between mental and physical health, our patients stand to gain.

Co-author David Ring, MD, PhD shares his perspective on this study in the related Author Insights video, found here.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media