Introduction
As individuals age, physical impairments may have a
deleterious effect on the musculoskeletal system (1). Distal radius fractures (DRF) are a
commonly encountered type of traumatic injury in daily practice.
The incidence of osteoporosis-associated DRF has been reported to
increase from approximately the age of 70 years (2). DRF associated with osteoporosis are
frequently identified as the earliest manifestation of fragility
fractures, which precede other osteoporotic fractures (3). The number of patients with DRF is
expected to continue to rise due to the increasing age of the
global population (2). The World
Health Organization has recognized osteoporotic fractures and
associated morbidity as important health issues globally (4).
Volar locking plate fixation enables early
postoperative return to daily activities. It has increasingly been
indicated not only for elderly patients but also for adolescents
(5). However, from the patient's
perspective, undergoing surgery can pose substantial challenges,
such as psychological stressors associated with the illness itself,
anesthesia, surgical outcomes and postoperative recovery (6). In particular, the perioperative
period is considered a time of high psychological stress (6). Furthermore, preoperative patients
with orthopedic diseases are concerned about their postoperative
physical condition and anxious about postoperative restrictions on
physical movement (7).
The central sensitization inventory (CSI) score is a
patient-reported outcome used to identify symptoms associated with
a central sensitization syndrome (8). It was recently reported that the CSI
score can be used as an assessment tool for psychosocial factors in
pain assessment (9). In the
present study, the use of the CSI score to assess the psychosocial
factors of patients' status before surgery for DRF was
investigated. Furthermore, factors influencing the CSI score before
surgery for DRF were investigated.
Patients and methods
Ethical approval
This study was approved by the Research Ethics
Committee of the Faculty of Medicine, Juntendo University (Tokyo,
Japan; approval no. E22-0447; date of approval: November 11, 2024).
This committee is registered with the Ministry of Health, Labour
and Welfare's Research Ethics Review Committee Reporting System in
accordance with Japanese ethical guidelines (Institutional Review
Board no. 21000123). This study was retrospective and was approved
by the Research Ethics Committee of the Faculty of Medicine,
Juntendo University (Tokyo, Japan) to be conducted using an opt-out
approach rather than written informed consent. In accordance with
the ethical guidelines, the requirement for written informed
consent was waived due to the retrospective design of the study.
Instead, information about the study and the opportunity to opt out
were provided on the hospital website. Furthermore, an opt-out
approach was implemented to ensure that patients had the
opportunity to decline participation. The study was conducted in
accordance with the principles of the Declaration of Helsinki.
Study design and patient
selection
Of the 37 patients who underwent volar locking plate
fixation for DRF at our hospital between January and September
2024, 22 patients with available preoperative CSI scores were
included in this study, while 15 patients without CSI score were
excluded. During the study period, completion of the CSI score was
voluntary and not mandatory in routine clinical practice.
Therefore, patients without available preoperative CSI score were
excluded from the analysis.
Study objective and variables
The aim of this study was to analyze the clinical
factors associated with preoperative CSI scores in patients DRF.
The study variables included sex; side of injury; fracture type;
age; the interval (in days) from injury to the preoperative
assessment at which the questionnaires were completed; numerical
rating scale (NRS); quick disabilities of the arm, shoulder and
hand (Q-DASH) score; and CSI score.
Outcome measures
The CSI score is a self-reported questionnaire
consisting of 25 items, each scored from 0 to 4, yielding a total
score ranging from 0 to 100, with higher scores indicating greater
central sensitization (10). The
NRS was used to assess pain intensity, ranging from 0 (no pain) to
10 (worst imaginable pain) (11).
The Q-DASH score was used to evaluate upper extremity disability;
it consists of 11 items scored on a 5-point Likert scale and is
transformed to a score ranging from 0 to 100, with higher scores
indicating greater disability (12).
Variable definitions
To quantify qualitative data, sex was coded as 0 for
male and 1 for female; side of injury as 0 for the dominant hand
and 1 for the non-dominant hand; and fracture type as 0 for
extra-articular or partial intra-articular fractures and 1 for
complete intra-articular fractures. Fractures were classified
according to the AO classification: Extra-articular fractures were
classified as type A, partial intraarticular fractures as type B
and complete intra-articular fractures as type C. Age, interval
from injury to evaluation (in days), NRS and Q-DASH scores were
treated as continuous variables, and their association with the CSI
score was statistically analyzed.
Statistical analysis
Categorical variables (sex, side of injury and
fracture type) were analyzed by Mann-Whitney U analysis and
continuous variables (age, interval from injury to evaluation in
days, NRS and Q-DASH score) were analyzed using bivariate analysis
with Pearson's correlation coefficient. Furthermore, variables that
demonstrated significant associations in the univariate analysis
were included in a multiple linear regression analysis to identify
independent predictors. Model goodness-of-fit in the multiple
linear regression analysis was evaluated using the overall F-test
and the coefficient of determination (R²). A post-hoc power
analysis was performed for the multiple linear regression model
using the observed effect size, sample size and number of
predictors.
Results
Patient characteristics
In this study, 7 patients were male and 15 female;
12 had injuries on the dominant side and 10 on the non-dominant
side; 8 patients had extra-articular or partial intra-articular
fractures and 14 had complete intra-articular fractures; the mean
age was 60.6±12.3 years; the interval (in days) from injury to
evaluation was 4.7±2.6 days; the NRS score was 6.1±2.8; and the CSI
score was 19.2±12.4 (Table I).
 | Table IRelationship between CSI score and
each of the evaluation items. |
Table I
Relationship between CSI score and
each of the evaluation items.
| Evaluation items | Results | Correlation with CSI
score | P-value and
correlation coefficient |
|---|
| Sex (0, male; 1,
female) | 0:7; 1:15 | (-) | P=0.389 |
| Side of injury (0,
dominant side; 1, non-dominant side) | 0:12; 1:10 | (-) | P=0.774 |
| Fracture type (0,
extra-articular or partial intra-articular fracture; | 0:8; 1:14 | (-) | P=0.063 |
| 1, complete
intra-articular fracture) | | | |
| Age, years | 60.6±12.3 | (+) | P=0.049 |
| | | | r=0.424 |
| Interval from injury
to evaluation, days | 4.7±2.6 | (-) | P=0.529 |
| | | | r=-0.142 |
| NRS | 6.14±2.8 | (+) | P=0.003 |
| | | | r=0.607 |
| Q-DASH score | 55.6±25.1 | (-) | P=0.385 |
| | | | r=0.195 |
| CSI score | 19.2±12.4 | / | / |
Univariate and correlation
analyses
Univariate analysis of the relationship between CSI
score and each of the evaluation items showed no significant
relationships between CSI score and sex (P=0.389), side of injury
(P=0.774) or fracture type (extra-articular fracture, partial
intra-articular fracture or complete intra-articular fracture)
(P=0.063), and neither was there a correlation with the interval
(in days) from injury to evaluation (P=0.529, r=-0.142) or Q-DASH
score (P=0.385, r=0.195). On the other hand, there were significant
correlations between the CSI score and age (P=0.04, r=0.424) and
NRS (P=0.003, r=0.607) (Table
I).
Multiple linear regression
analysis
Age and NRS showed significant associations with CSI
score in the univariate analyses; therefore, multiple linear
regression analysis was performed to further examine these
relationships. The overall regression model was statistically
significant (F=11.02, P=0.0007), explaining 53.7% of the variance
in CSI scores (R²=0.537, adjusted R²=0.488) (Table II). In the multivariable model,
both age (B=0.424, P=0.0165) and NRS (B=2.721, P=0.0011) were
independently associated with the CSI score (Table II). Specifically, each 1-year
increase in age was associated with a 0.424-point increase in the
CSI score, and each 1-point increase in NRS was associated with a
2.721-point increase in the CSI score.
| Table IIMultivariable linear regression
analysis of factors associated with the central sensitization
inventory score. |
Table II
Multivariable linear regression
analysis of factors associated with the central sensitization
inventory score.
| Variable | B | SE | b | 95% CI | P-value |
|---|
| Age, years | 0.424 | 0.161 | 0.421 | 0.086-0.762 | 0.0165 |
| NRS | 2.721 | 0.711 | 0.615 | 1.238-4.209 | 0.0011 |
Discussion
The present study investigated factors associated
with the CSI scores before volar locking plate fixation for DRF.
Factors investigated included patient features (sex, side of injury
and age), fracture-related variables (fracture type and interval
from injury to evaluation in days) and patient-reported outcomes
(NRS and Q-DASH scores). It was found that the CSI score was
significantly associated with age and NRS.
It has been reported that postoperative pain is more
intense in female fracture patients than in male fracture patients
(13). This suggests that sex may
influence pain perception following trauma and it was included as a
variable in the analysis. However, no significant association
between the CSI score and sex was found. Iitsuka et al
(14) investigated differences in
postoperative functional recovery between dominant and non-dominant
side injuries in patients who underwent volar locking plate
fixation for DRF. They reported that patients with dominant-side
injuries showed significantly greater postoperative improvement in
hand joint range of motion and grip strength than those with
non-dominant-side injuries (14).
Therefore, it was hypothesized that the side of injury (dominant or
non-dominant side) influences pain after fracture treatment and
preoperative CSI score. However, no significant relationship was
found between the side of injury and CSI score. DRF involving the
articular surface have been reported to be associated with poorer
functional outcomes compared with extra-articular fractures
(15). Furthermore, at 6 months
postoperatively, patients with complete intra-articular fractures
(AO classification type C) have been shown to experience
significantly greater pain than those with partial intra-articular
fractures (AO classification type B) (16). Based on these findings, it was
hypothesized that the fracture type influences preoperative CSI
scores. On the other hand, as the cohort of the present study
included only three type A fractures, five type B fractures and 14
type C fractures, types A and B were combined into a single group
and compared with type C for statistical analysis. As a result, it
was found that the type of fracture (extra-articular or
intra-articular fractures) was not related to the preoperative CSI
score. Wilson et al (17)
reported that pain was inversely correlated with the interval from
injury to initial consultation and initial response for DRF.
Therefore, it was hypothesized that the interval (in days) from
injury to evaluation influences preoperative CSI scores; however,
no significant association was found. Patient-reported outcomes
that assess pain and directly reflect quality of life have gained
attention as important measures in evaluating wrist function.
Kawamura et al (18)
reported that the visual analogue scale and grip strength were
associated with Q-DASH scores after volar locking plate fixation
for DRF. The Q-DASH score is a widely used patient-reported outcome
measure for the upper extremities and has been employed in previous
studies that evaluated the outcomes of DRF (19). However, in the present study, no
significant relationship was found between the Q-DASH and CSI
scores.
In the present study, it was found that age and NRS
had a significant association with the CSI score. Furthermore, the
NRS had a greater impact on the CSI scores than age. Older age
decreases the ability of patients to cope with emotional stress and
control their emotions in response to stressful events such as
anxiety and depression (20). In
the present study, patients' CSI scores were investigated in
response to being informed of a DRF diagnosis and the subsequent
recommendation for surgical treatment. It was found that the CSI
score was significantly associated with age and was higher with
increasing age. Pain is classified into three categories:
Nociceptive pain, neuropathic pain and psychosocial pain (21). The results of the present study
that the NRS, a measure of nociceptive pain, was related to the CSI
score supports those of a previous study (22). The present findings suggest that
nociceptive pain intensity is positively associated with central
sensitization in the preoperative state before DRF surgery,
highlighting the importance of pain assessment prior to
surgery.
In the present study, the mean CSI score before
volar locking plate fixation for DRF was 19.2±12.4, and 9.1% (2
patients) of the cohort had a CSI score of 40 or higher. A CSI
score of 40 or higher has been proposed as a clinically relevant
cutoff indicating the presence of central sensitization-related
symptoms (10). Previous reports
have shown that the mean CSI score was 16.1±11.1 in patients with
chronic low back pain, with 4.4% scoring 40 or higher (22). In addition, the mean CSI score in
patients with hip osteoarthritis was 19.5±11.3, with 5.0% scoring
40 or higher (23). Compared with
these reports, the CSI scores of patients before volar locking
plate fixation for DRF are not lower than those reported for other
musculoskeletal disorders. Furthermore, CSI is used not only as a
diagnostic indicator for central sensitization syndrome but also as
an indicator of psychosocial factors, such as anxiety and
depression (9). Therefore, in the
present study, CSI scores were regarded as an indicator of
psychosocial factors, and it was evaluated how CSI scores are
associated with activities of daily living impairment in patients
before volar locking plate fixation for DRF.
This study has several limitations. First, the
sample size in this study was relatively small (n=22). Post-hoc
power analysis demonstrated that the statistical power for the
correlation between the NRS and CSI score was sufficient
(power=0.882), whereas the power for the association between age
and CSI score was moderate (power=0.522). In addition, the
multivariable linear regression model showed high statistical power
(power=0.99). Although the primary associations observed in this
study appear to be statistically robust, the finding regarding age
should be interpreted with caution due to its moderate power.
Further studies with larger sample sizes are warranted to validate
this association. Second, Multivariate analysis was performed;
however, due to the small sample size (n=22), the number of
covariates that could be included in the model was limited.
Inclusion of additional variables in such a small cohort may
increase the risk of model overfitting and unstable estimates, as
described by Riley et al (24). Therefore, potential confounding
factors such as psychological comorbidities (e.g., anxiety and
depression), osteoporosis and psychosocial background were not
included in the final model (25-27).
Thus, a certain degree of residual confounding may remain. Previous
studies have demonstrated that these factors may influence pain
perception and central sensitization (25,26).
Accordingly, an independent association between CSI and clinical
outcomes cannot be definitively established. Future studies with
larger sample sizes and multivariate models are warranted to
confirm these findings. Furthermore, for the same reason, detailed
subgroup analyses according to specific AO fracture classifications
were not performed, as dividing this small cohort into multiple
subgroups would substantially reduce statistical power and increase
the risk of unstable estimates. Accordingly, the independent
association between CSI and clinical outcomes cannot be
definitively established. Future studies with larger sample sizes
and multivariate models are warranted to confirm these findings.
Third, this study evaluated only the preoperative clinical status.
Therefore, the impact of preoperative CSI scores on postoperative
pain and functional recovery remains elusive. Longitudinal studies
with follow-up assessments are required to determine the predictive
value of CSI. Finally, because the completion of the CSI score was
voluntary, data were missing in a subset of eligible patients,
which may have introduced selection bias.
In conclusion, CSI scores were significantly
associated with age and NRS before volar locking plate fixation for
DRF. Mental stress management and nociceptive pain relief for
elderly patients may be useful in preoperative patient care.
Acknowledgements
Not applicable.
Funding
Funding: Not applicable.
Availability of data and materials
The data generated in the present study may be
requested from the corresponding author.
Authors' contributions
SI mainly wrote the manuscript, and performed
acquisition, analysis and interpretation of data. KN and MI were
involved in the conception and design of this study. NI, TS, KK, SK
and TI participated in the acquisition analysis and interpretation
of data. SI and KN confirm the authenticity of all the raw data.
All authors have read and approved the final version of the
manuscript.
Ethics approval and consent to
participate
The study was approved by the Ethics Committee for
Medical Research of Juntendo University (Tokyo, Japan; approval no.
E22-0447; date of approval: November 11, 2024).
Patient consent for publication
Informed consent was obtained for participation and
publication by opt-out on a website. Patients who declined to
provide consent were excluded.
Competing interests
The authors declare that they have no competing
interests.
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