Brad K. Grunert

Psychological adjustment following work-related hand injury : 18-month follow-up

Severe, work-related hand injuries are often accompanied by a significant number of psychological symptoms that are frequently associated with posttraumatic stress disorders. These symptoms occur in the following four domains of psychological functioning: cognitive, affective, physiological, and behavioral. This study examined the incidence of a variety of symptoms occurring with work-injured patients. Interviews were conducted at 1 week, 3 months, 6 months, 12 months, and 18 months after injury. Symptom frequencies were recorded. The results indicate that many of these symptoms were persistent 18 months later and continued to be significantly debilitating. The results support the need for psychological intervention after severe, work-related hand injuries.

Early psychological aspects of severe hand injury

We investigated the incidence and nature of psychological symptoms occurring during the first two months after severe hand injuries. 94% of patients had significant symptoms at some point early in rehabilitation, including nightmares (92%), flashbacks (88%), affective lability (84%), preoccupation with phantom limb sensations (13%), concentration/attention problems (12%), cosmetic concerns (10%), fear of death (5%), and denial of amputation (3%). Two months later, flashbacks (63%) remained pronounced. Nightmares (13%), affective lability (48%), concentration/attention problems (5%), fear of death (0%), and denial of amputation (0%) declined markedly, while cosmetic concerns (17%) and preoccupation with phantom limb sensations (17%) increased. Based on these findings, we believe that psychological treatment should often be given as part of the rehabilitation process.

Treatment of posttraumatic stress disorder after work-related hand trauma

Posttraumatic stress disorder frequently accompanies severe work-related hand trauma and, when a patient attempts to return to work it can potentially be as debilitating as the hand injury. Four techniques were examined for their effectiveness in the treatment of the symptoms of posttraumatic stress disorder. Confronting and reprocessing of intrusive thoughts, combined with coping skills training, effectively reduced all symptoms except avoidance reactions. An early return to the worksite was useful with those patients who experienced mild avoidance reactions, although many patients were not able to use this. Graded work exposure was a highly successful technique for those patients with moderate avoidance reactions. For those with severe avoidance reactions, on-site job evaluations were used with good success. We believe that actual exposure to the worksite greatly enhances the ability of occupationally hand-injured patients to return to work for their previous employer. An algorithm for treatment is proposed.

psychological Adjustment in Children after Traumatic Disfiguring Injuries: A 12-month Follow-up

&NA; The psychological adjustment of 57 children (age range, 3 to 12 years) who sustained mutilating traumatic injuries to the face or upper or lower extremities was assessed over a 12‐month interval. The injuries had occurred as a result of boating, lawn mower, or home accidents or dog bites. Within 5 days of the traumatic event, 98 percent of the children were symptomatic for posttraumatic stress disorder, depression, or anxiety. One month after the injury, 82 percent were symptomatic. Symptom frequency had declined by the time of the 3‐month and 6‐month evaluations, but 44 percent of the children continued to report symptoms at 12‐month follow‐up visits, and 21 percent met the diagnostic criteria for posttraumatic stress disorder. Typical symptoms included flashbacks, fear of re‐injury, mood disorders, body‐image changes secondary to disfigurement, sleep disturbances, and anxiety. These findings support the importance of psychological evaluation and treatment of children who suffer mutilating injuries that require the attention of plastic surgeons. (Plast. Reconstr. Surg. 106: 1451, 2000.)

Flashbacks after traumatic hand injuries: Prognostic indicators

Flashbacks of a traumatic hand injury may compromise a patients rehabilitation process. This study examined the nature and significance of these flashbacks in a work-injured population. We also evaluated the ability of these patients to return to work at the site of the original injury. Sixty-one patients with work-related, traumatic hand injuries received psychological evaluation and treatment. All patients experienced flashbacks. The following three types of flashbacks were identified: (1) a replaying of the events occurring just before the accident and continuing until the injury (replay flashbacks), (2) an image of the injured hand just after the trauma occurred (appraisal flashbacks), and (3) images in which an injury that was more severe than the one that actually occurred were perceived (projected flashbacks). Regardless of the result of injury, patients with replay flashbacks were the most likely to return to their former employment (95.2%) after only 4.8 1-hour sessions of psychotherapy for control of symptoms. Patients with a combination of appraisal and projected flashbacks were the least likely to return to work (10.3%), despite the fact they received an average of 13.1 1-hour sessions of psychotherapy.

Analysis of the distribution of cutaneous perforators in cutaneous flaps

&NA; An anatomic and statistical analysis was performed on the distribution of cutaneous perforators that perfuse the scapular, radial forearm, and lateral arm cutaneous flaps. Perforators were categorized as direct, terminal, and intransit, depending upon perforator origin and termination site relative to the source artery. Statistical cluster analysis of perforator distributions was performed to determine the regions in which cutaneous perforators are consistently found. The scapular and radial forearm flaps could be divided into up to three well‐perfused segments. The analysis predicted the possibility of dividing the lateral arm flap into as many as seven segments while maintaining perfusion. Clinical applications of this method for preoperative flap design and elevation as well as final results are shown. (Plast. Reconstr. Surg. 101: 72, 1998.)

Classification system for factitious syndromes in the hand with implications for treatment

We evaluated 29 patients with factitious disorders in the hand who received Workers Compensation benefits. Three types of factitious hand disorders based on physical presentation were self-mutilation and wound manipulation, edema, and finger and hand deformities. Two distinct psychological diagnoses present were factitious disorder with physical symptoms and conversion disorder. The Minnesota Multiphasic Personality Inventory revealed two personality profiles: emotionally dependent and angry and hostile. Behavioral treatment was implemented. The emotionally dependent group responded well, with 80% returning to work. The angry and hostile group had a much poorer response, with 21% returning to work. None of the self-multilating patients returned to work. We recommend a combined evaluation by a physician, a psychologist, and a hand therapist to achieve a definitive diagnosis for these disorders. The identification of psychological profiles assists in ascertaining which patients will be responsive to behavioral treatment.

Predictive value of psychological screening in acute hand injuries

Difficulties in adjustment frequently accompany severe hand injuries. The purpose of this study was to determine whether presurgical screening could predict long-term adjustment problems. One hundred thirteen patients with severe hand injuries completed a presurgical questionnaire evaluating flashbacks, avoidance, and causal factors pertaining to the injury. Patients were evaluated by a psychologist within 5 days after surgery and again 6 months later. Flashbacks initially occurred with equal frequency in occupationally and nonoccupationally injured groups. At 6-month follow-up 50% of the occupationally injured patients and 25% of the nonoccupationally injured patients had flashbacks. Avoidance of the activity at which patients were injured was also assessed. Among occupationally injured patients, 52% initially reported no avoidance compared with 17% at follow-up. Patients with nonoccupational injuries showed more initial avoidance (68%), with slightly less at follow-up (61%). Of the occupationally injured patients, 46% initially reported personal error or fatigue as the cause of their injury, but only 6% reported this as the cause at follow-up; it is interesting that at 6-month follow-up 81% of this group reported machine failure or lack of safeguards. Among nonoccupationally injured patients, 71% reported personal error as the cause of injury presurgically and 66% at 6-month follow-up. Presurgical screening appears to be a valid means of identifying persons at risk of ongoing adjustment problems after hand injury. A screening interview can easily be conducted in less than 5 minutes.

Graded work exposure to promote work return after severe hand trauma: a replicated study

Fifty-one patients with posttraumatic stress disorder after work-related hand injuries were placed on a graded work exposure program to facilitate return to work. These patients consisted of an initial group of 25 patients and a replication group of 26 patients. The program returned 92% of the initial group and 88% of the replicated group to work with their previous employers. At 6-month follow-up, 88% of the initial group and 80.1% of the replication group were still working full-time at the jobs to which they had returned. All of the patients not working with their previous employer at follow-up had appraisal/projected flashbacks, which have previously been associated with a 90% failure to return to work. This intervention was successful with 73% of the patients experiencing such flashbacks. In conclusion, graded work exposure was an effective treatment to promote return to work for patients experiencing significant psychological symptomatology after severe hand injury.

Thermal self-regulation for pain control in reflex sympathetic dystrophy syndrome

Reflex sympathetic dystrophy syndrome is comprised of a variety of changes in vasomotor and trophic responsivity, as well as, stiffness, edema and severe pain. This study examined 20 patients with reflex sympathetic dystrophy syndrome who had failed to respond to a variety of techniques commonly used to treat this disorder. These patients had documented histories of reflex sympathetic dystrophy syndrome ranging from 18 to 60 months. All had been referred for psychological evaluation and provision of pain management. A combination of thermal biofeedback, relaxation training, and supportive psychotherapy were used to reduce subjective pain. The results indicate that patients were able to significantly increase their initial ( p p p