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The relationship between hand function, depression, and the psychological

impact of trauma in patients with traumatic hand injury

Article  in  International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation · November 2013
DOI: 10.1097/MRR.0000000000000040 · Source: PubMed

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The relationship between hand function, depression,
and the psychological impact of trauma in patients
with traumatic hand injury
Beril Dogua, Banu Kurana, Hulya Sirzaib, Sinem Sagc, Nuray Akkayad
and Fusun Sahind
The aim of this study was to investigate the acute-stage
and later-stage impacts of trauma on a patient, and to
determine the relationship between the degree of the
impact of the event and recovery of hand function in
patients with traumatic hand injury. The functional
status of patients was assessed by the Disabilities
of the Arm, Shoulder, and Hand (DASH) questionnaire;
c 2014 Wolters Kluwer Health |
psychological influence was assessed by the Beck
Depression Inventory (BDI); and the impact of the event
was assessed by the Impact of Event Scale-Revised
(IES-R) both during the acute stage and at a later stage.
Fifty-four patients completed the study. The DASH, BDI,
and IES-R scores were significantly improved at a later
stage compared with the acute stage (P < 0.05). The DASH,
BDI, and IES-R scores had significant positive correlations
with each other in both the acute stage and later stage
(P < 0.05). In the linear regression analysis, the
independent variables affecting the DASH score at a later
stage were the DASH and IES-R scores in the acute stage
(P < 0.05), whereas depression scores had no effect on
functional outcome (P > 0.05). Our study suggests that
Introduction
Throughout human history, the hand has been defined as a
unique part of the body as it enables us to perform
occupational activities. The hand is one of the most
important components of body image, and the hands are
used in nonverbal body communication (Jaquet et al.,
2005; Lundborg and Rosén, 2007; Hannah, 2011). Hand
injuries can result in severe physical problems that may
affect one’s ability to perform daily activities and they
may also cause symptoms such as pain, dysesthesia, and
cold intolerance (Lundborg and Rosén, 2007; Williams et al.,
2009). A nonfunctional hand may also lead to insecurity,
incompetence, and dependency, all of which can give rise
to negative psychological effects in an individual (Schier
and Chan, 2007; John and Verma, 2011).
Past studies have focused on the psychological status of
individuals following work-related hand injury. Those
studies indicate that stress–anxiety disorders, major
depression, and post-traumatic stress disorder (PTSD)
are common in these patients (Mendelson et al.,
1986; Cohen, 1987; Grunert et al., 1992; Gustafsson and
Ahlstrom, 2004). Acute stress disorder has been observed
in up to 94% of patients, and major depression and PTSD
0342-5282
c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Original article 105
depression status, functional status of the hand, and
impact of the event improve at a later stage, and that the
functional outcome at a later stage is affected by the
degree of impact of the event, and the functional status
of the hand in the acute stage, in patients with traumatic
hand injury. International Journal of Rehabilitation
Research 37:105–109
Lippincott Williams & Wilkins.
International Journal of Rehabilitation Research 2014, 37:105–109
Keywords: hand function, hand injury, impact-of-event, trauma
a
Department of Physical and Rehabilitation Medicine, Sisli Etfal Education
and Research Hospital, Istanbul, bAnkara Physical Medicine and Rehabilitation
Education and Research Hospital, Ankara, cDepartment of Physical and
Rehabilitation Medicine, Sakarya Education and Research Hospital, Sakarya and
d
Department of Physical Medicine and Rehabilitation, Faculty of Medicine,
Pamukkale University, Denizli, Turkey
Correspondence to Fusun Sahin, MD, MSc, Department of Physical Medicine
and Rehabilitation, Faculty of Medicine, Pamukkale University,
20070 Kınıklı-Denizli, Turkey
Tel: + 90 535 3578373; fax: + 90 258 2118129;
e-mail: drfusunsahin@yahoo.com.tr
Received 4 May 2013 Accepted 17 October 2013
are common among these individuals, characterized by
symptoms such as flashbacks, nightmares, concentration
and attention disorders, and mood swings (Grunert et al.,
1988). Flashbacks and nightmares are the most common
symptoms, and the presence of these symptoms in the
first 1–3 months following injury is considered as
the main reason behind the persistence of emotional
stress (Cohen, 1987; Grunert et al., 1992). Following the
injury, the symptoms of acute traumatic stress disorder
decrease over 1 month in patients with traumatic hand
injury (Meyer, 2003). If these symptoms persist with the
same degree of severity for more than 1 month, the
clinical diagnosis is defined as PTSD. It is seen in B50%
of hand-injury patients (Grunert et al., 1990, 1992; Hen-
nigar et al., 2001; Koestler, 2010). Grunert et al. (1992)
suggest that although the psychological impact is at its
worst in the first few months following the injury,
patients may still experience some psychological pro-
blems, and have flashbacks and fear of reinjury even after
18 months. Considering that the psychological impact
may be prolonged, during the assessment phase and the
following period, psychopathological symptom evaluation
with the biopsychosocial approach may also contribute to
better patient compliance and a better treatment process,
DOI: 10.1097/MRR.0000000000000040
106 International Journal of Rehabilitation Research 2014, Vol 37 No 2
and may enable the patient to achieve an improved
functional outcome. The degree of resulting disability is
determined by the patients’ perception of loss, and
through their adoption of their new hand form and
adaptability to it (Brown, 1996). The relationships among
tissue injury, trauma severity, functional impairment, and
psychological compliance to the traumatic injury have
been examined in several previous studies. According to
the results of these studies, the duration and persistency
of the impact of the trauma differ according to the cause
and the physical location of the trauma (Lee et al.,
1985; Sheffield et al., 1988; Craig et al., 1994).
In our hand rehabilitation unit, outpatient follow-up
takes place for 3 h a week in a clinic for patients in need
of rehabilitation due to hand and upper-extremity
problems, involving a team consisting of physicians and
physiotherapists. A wide range of patients residing in the
local urban area or patients who are referred to us from
the surrounding health centers in rural areas – including
those with tendon or nerve injury and complex regional
pain syndrome, and children with brachial plexus injury –
are followed up at our clinic. During our follow-up it has
been observed that some of the patients exhibit
psychological problems following hand injury.
For the present study, it was hypothesized that the
psychological impact of a traumatic event would affect
the functional state and outcome negatively. As a result,
we investigated the relationship between the impact of
the trauma in the acute stage and at a later stage,
considering both hand function and depression level in
patients with traumatic hand injuries.
Methods
Study population
Patients with an injury to only one hand, operated on and
referred to our hand rehabilitation unit after the trauma
for the purpose of rehabilitation, were included in this
longitudinal study. Their age, education level, employ-
ment status, hand dominance, site of injury, elapsed time
since trauma, and causes of trauma were recorded.
Patients under the age of 18 years, those with congenital
hand abnormalities, individuals who cannot read or write
in Turkish, patients who, because of the extent of their
injuries, are still immobilized at the time of the first data
collection period, and those who had been already treated
elsewhere were excluded.
Procedures
The first evaluation was performed during the acute
postoperative stage (i.e. within the first 3 months) and the
second evaluation was performed at a later stage (i.e. 6–9
months postoperatively). For both evaluations, all patients
filled out the questionnaires. The procedures followed in the
study were approved by the local ethics committee and
informed consent was provided by all participants.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Evaluation parameters
Upper-extremity functions by the Disabilities of the Arm,
Shoulder, and Hand (DASH) and depression by the Beck
Depression Inventory (BDI) were assessed. The Impact
of Event Scale-Revised (IES-R) was used to assess the
impact-of-event level.
The DASH questionnaire was developed in 1994 by
the American Academy of Orthopedic Surgeons (AAOS)
and assesses function and disability following upper-
limb injury. The questionnaire consists of 30 questions:
21 questions evaluate difficulty with specific tasks; five
questions evaluate symptoms (two of them evaluate pain
and the rest, respectively, numbness, stiffness, and
weakness), and one question each evaluates social
function, work function, sleep, and confidence. Each
question is answered on a five-point Likert scale. Total
scores range from 0 to 100, with higher scores indicating
greater loss of upper-limb function (Hudak et al., 1996).
The BDI is a self-assessment tool that consists of 21
items: it evaluates depressive symptoms such as sadness;
anhedonia; depressive cognitions of guilt, punishment,
and suicide; various somatic symptoms; and attitudes
reflecting one’s current state. Each item is scored
between 0 and 3, with total scores ranging from 0 to 63.
A total score of 0–7 is considered to be within the
‘normal’ range, 8–13 is within the ‘minimal’ range, 14–19
is ‘mild,’ 20–28 is ‘moderate,’ and 29–63 is ‘severe’.
A higher score indicates more pronounced depressive
symptoms (Hisli, 1989).
The IES-R evaluates stress in patients who have experi-
enced a traumatic event. The questionnaire assesses the
trauma-related stress experienced within the last 7 days.
The IES-R is composed of three subscales (intrusion,
avoidance, and hyperarousal) and a total of 22 questions
that are scored between 0 and 4. However, as there have
been minimal data using the IES-R for discrete cutoff
scores, Improving Access to Psychological Therapy suggests
a cutoff score of 33 or above (Çorapçıoğlu et al., 2006).
Statistical analysis
Statistical analysis was performed through the use of
SPSS 17 software (SPSS Inc., Chicago, Illinois, USA). In
addition to the descriptive statistical methods (mean,
SD) used to analyze data, the Wilcoxon test was used to
determine changes in the evaluation parameters before
and after treatment. Pearson’s correlation analysis was
performed to determine associations among clinical
variables (acute-stage and later-stage IES-R, BDI, and
DASH). Linear regression analysis was performed for the
variables that showed significant associations to deter-
mine their effects on DASH scores at a later stage. (At a
later stage, the DASH score is the dependent variable
whereas in the acute stage, DASH, BDI, and IES-R scores
are the independent variables). Statistical significance
 Hand function and trauma’s impact Dogu et al. 107

was set to the P value less than 0.05 level, with a 95% According to the BDI scores for 54 patients, while in the
confidence interval. acute stage 33.3% (n = 18) scored within normal limits,
25.9% (n = 14) scored minimal, 16.6% (n = 9) scored
mild, 16.6% (n = 9) scored moderate, and 7.4% (n = 4)
Results scored for severe depression, in the later stage, 66.6%
Study population (n = 36) scored within normal limits, 18.5% (n = 10)
A total of 57 patients were initially included in the study. scored minimal, 3.7% (n = 2) scored mild, 5.5% (n = 3)
As one of the patients was incarcerated and two of them scored moderate, and 5.5% (n = 3) scored for severe
did not turn up for later-stage evaluation, the study was depression.
completed with 54 patients.
In terms of the correlation between the mean IES-R,
Of these 54 patients, four were female (7.4%) and 50 DASH, and BDI scores, all three parameters were
were male (92.6%); their mean age was 31.04±9.8 years. significantly and positively correlated with each other in
At the time of injury, six patients were students, 42 were both the acute and later stage (Table 3). Whereas the
employees, five were self-employed, and one was a acute-stage BDI score had no effect on functional
housewife. The dominant hand of 34 patients and outcome, the later-stage DASH score was independently
nondominant hand of 20 patients were injured. Causes affected by the acute IES-R scores according to the linear
of injury included punching glass (n = 16), industrial regression analysis (Table 4).
accidents (n = 20), home accidents (n = 13), hobby
accidents (n = 4), and a motor vehicle accident (n = 1).
Mean duration between the operation and the first Table 2 DASH, BDI, and IES-R scores in acute and later stage
evaluation, which was executed in the acute stage, was Acute stage Later stage P
7.28±2.66 weeks, whereas mean duration between the DASH 40.4±21.89 13.5±15.2 0.001
operation and the second evaluation, which was executed 7.5–92.5 0–71.7
at a later stage, was 34.87±5.5 weeks. The characteristics BDI 13.1±10.2 7.1±9.3 0.001
0–39 0–38
of the patients are listed in Table 1. IES-R intrusion 10.6±7.2 5.8±6.5 0.001
0–29 0–32
The mean DASH and BDI scores and the mean IES-R IES-R avoidance 12.9±7.8 7.4±7.1 0.001
total and subscales (intrusion, avoidance, hyperarousal) in 0–30 0–28
IES-R hyperarousal 6.4±5.9 2.9±4.5 0.001
the acute and later stage are represented in Table 2. The 0–24 0–22
mean DASH scores were found to be significantly higher IES-R total score 29.8±18.4 16.0±16.8 0.001
in the acute stage (40.4±21.89 in the acute stage vs. 2–79 0–82

13.5±15.2 at the later stage). The mean BDI scores
decreased from 13 to 7, and IES-R total and subscale
scores also decreased by about half at B28 weeks. Mean
BDI and IES-R scores significantly decreased at the later
stage compared with the acute stage (P = 0.001).
BDI, Beck Depression Inventory; DASH, Disabilities of the Arm, Shoulder, and
Hand Questionnaire; IES-R, Impact of Event Scale-Revised.
Table 3 Relationships among IES-R, BDI, and DASH in acute
and later stage
P r

Table 1 Demographic and clinical characteristics of patients Acute-stage IES-R–acute-stage BDI 0.001 0.569
Acute-stage IES-R–acute-stage DASH 0.008 0.356
n (54) Acute-stage DASH–acute-stage BDI 0.05 0.373
Later-stage IES-R–later-stage BDI 0.001 0.800
Age (years) [mean (SD)] 31.04±9.8 Later-stage IES-R–later-stage DASH 0.001 0.520
Sex Later-stage DASH–later-stage BDI 0.001 0.558
Female 4
Male 50 BDI, Beck Depression Inventory; DASH, Disabilities of the Arm, Shoulder, and
Occupation Hand Questionnaire; IES-R, Impact of Event Scale-Revised; r, Pearson’s
Student 6 correlation coefficient.
Employed 42
Self-employed 5
Housewife 1
Affected hand Table 4 Linear regression analysis for DASH scores in later stage
Dominant 34
Nondominant 20 B SE b P
Type of trauma
Hitting glass 16 Later-stage DASH score
Work accident 20 Acute-stage IES-R 0.234 0.09 0.284 0.012
Home accident 13 Acute-stage DASH 0.365 0.074 4.94 0.001
Hobby accident 4
Traffic injury 1 In linear regression model (R2 = 0.476, model is backward): dependent variable,
Duration since operation (weeks) [mean (SD)] DASH score of later stage; independent variables, acute-stage DASH, acute-
Acute stage (before treatment) 7.28±2.66 stage BDI, and acute-stage IES-R.
Later stage (after treatment) 34.87±5.5 B, odds ratio; DASH, Disabilities of the Arm, Shoulder, and Hand Questionnaire;
IES-R, Impact of Event Scale-Revised.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
108 International Journal of Rehabilitation Research 2014, Vol 37 No 2
Discussion
In the current study we examined the relationship
between functional outcome and the psychological
impact of the event in the acute stage and at a later
stage in patients with traumatic hand injury. The results
of this study indicate that the psychological impact of
the event reduces significantly within 6–9 months. The
results also show that the functional outcomes improve at
a later stage. The psychological impact of the event,
depression level, and hand function were found to be
correlated to each other both in the acute stage and at a
later stage.
Following an injury, patients may experience a broad
spectrum of emotional distress, including anxiety, depres-
sion, guilt, fear, frustration, sadness, and resentment
(Johnson, 1993). However, some patients cope with the
impact of an injurious event without experiencing
depression, anxiety, or PTSD (Lohman and Royeen,
2002; Meyer, 2003). Especially during the chronic period,
many other factors – such as having a good job, the
attribution of responsibility for an injury, pursuit of
litigation, and compensation claims – have been sug-
gested to affect psychological compliance and functional
recovery (Schnyder et al., 2001; Lohman and Royeen,
2002; Meyer, 2003; Rusch et al., 2003; Grob et al., 2008).
Typical symptoms of traumatic stress include an involuntary
re-experiencing of trauma, sleep disturbance, nightmares
or flashbacks, and the avoidance of trauma reminders
(Gustafsson et al., 2002; Gustafsson and Ahlstrom, 2004,
2006). Traumatic stress has been found to gradually decline
over the first 2 months of post-trauma. Even 1 year after
trauma, traumatic stress symptoms and depression persist
in nearly 50 and 20% of patients, respectively. In a study
by Jaquet et al. (2005) that re-evaluated 67 patients with a
wrist injury at 10 years post-trauma, it was found that their
IES scores had significantly declined from 26.6 in the first
postoperative month to 7.3 after 10 years. Similar to our
results for the later stage, the authors of that study
reported that the mean DASH score after the 10-year
evaluation period was 15.
In one study (Richards et al., 2011) examining functional
status, depression, and PTSD symptoms, at 16 months
postoperatively, the Q-DASH score was found to be 27,
and the PTSD score exceeded the threshold value.
Approximately one-third of the patients had high
depression and PTSD scores. Similar to the results of
the current study, the Q-DASH scores of that study were
found to correlate with depression and PTSD scores
among these patients in the chronic period. Jaquet et al.
(2002) report that the severity of trauma and functional
outcome correlated with high IES scores at an evalua-
tion performed 10 years postoperatively; similar results
were obtained in the current study among the acute-
stage patients with hand injury. The PTSD symptoms of
67 patients with acute injury have been found to correlate
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
with hand function (Opsteegh et al., 2010). In our study, we
do not evaluate the severity of the injury. Although the
DASH score has been reported as useful in data acquisition
regarding the degree of trauma severity (Eisenschenk et al.,
2012), the results of the current study suggest that severity
of injury is likely to correlate with the impact of the event,
given its relationship with the DASH and BDI scores in
both the acute and later stage. Another important finding
of the current study pertains to the relationship between
the acute-stage impact-of-event score and the later-stage
functional outcome; similar results were obtained by Jaquet
et al. (2002).
The presence of PTSD or depression has negative effects
not only on hand function, but also on overall quality of life
(Grob et al., 2008; Bailey et al. 2009; Williams et al., 2009). In
a study examining 106 patients with hand injuries using the
Short Form-36, as compared with other subgroups,
subgroups’ emotional role, body pain, social functioning,
and mental health exhibited significantly worse scores
(Williams et al., 2009). Inactivity stemming from problems
experienced in daily living activities has also been
suggested to have a negative impact on the mood of
patients and to result in a compulsory change in social role
(Gustafsson et al., 2002). In another study, Bailey et al.
(2009) report a physical loss of function as well as a
significant impairment in the psychological quality of life in
patients with nerve damage in the upper extremities; that
study found depression to be present in as many as 39% of
patients. In the current study, despite the fact that the
mean BDI score in the acute stage was higher than that of
the later stage, 33.4% of patients had a mild-to-severe
depression score in the later stage.
Although some studies (Johnson, 1993; Lohman and
Royeen, 2002; Grob et al., 2008) suggest that impaired
patient recovery and the occurrence of psychiatric
disorders such as anxiety and depression relate to a
patient’s current psychological profile, others report them
as being induced by injury (Johnson, 1993). Although the
premorbid psychological conditions of patients were
unknown, and their functional recovery was closely
related to the level of depression and the degree of
impact of the event in both the acute and chronic period,
the most effective factors vis-a`-vis functional recovery
were found to be the impact of the event and
the functional status of the acute period. Thus, the
investigation of the presence of comorbidities in patients
with PTSD may be useful in determining whether or not
functional recovery will be adversely affected. Reported
rates of association between PTSD and borderline
personality disorder of up to 50%, as well as similarities
between the symptoms of PTSD and attention deficit or
hyperactivity syndrome, suggest that it would be more
appropriate to approach the treatment of PTSD patients
from a psychiatric perspective (Zanarini et al., 1998;
Biederman, 2004; Rösler et al., 2009).

One of the limitations of the current study is that it did
not evaluate the presence of pain in the patients in terms
of it affecting their quality of life or social factors such as
the timing of their return to work. Another limitation of our
study is that we did not assess the severity of the injury.
Both the restoration of anatomical integrity and the
rehabilitation process following hand injury are of great
importance in achieving positive functional outcomes.
As found in our study, the psychological evaluation of
patients, taking into account the relationship between
the impact of the event and the functional outcome, will
help to provide appropriate and timely interventions and
to ensure their biopsychosocial well-being.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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