Patient Resilience, Is it Nature or Nurture?
Authors: Zona Nathaniel , Hunt Kenneth 
Published: December 2024

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Introduction/Purpose:

Resilience is a psychosocial factor gaining increased attention in foot and ankle orthopedic surgery due to its association with post-operative outcomes. Prior work shows low resilience, as measured by the Brief Resilience Scale (BRS), has been associated with significantly lower preoperative and post-operative patient reported outcomes (PROs) when compared to patients with high preoperative BRS scores. Furthermore, patients with high preoperative BRS scores demonstrate significantly better improvements in function and pain compared to low resilience patients. To date, there is no data assessing potential determinants of patient resilience. Understanding how patient characteristics, both intrinsic and modifiable, are associated with low preoperative BRS will help identify whether patient resilience is inherent or potentially modifiable and help inform the shared decision-making process for surgical intervention.

Methods:

Consecutive patients undergoing a foot and ankle procedure within a single institution’s automated PRO registry were screened for inclusion. The BRS scale was administered to each patient pre-operatively and at 6- and 12-months post-operative. BRS is a validated 6-item psychometric tool for assessing a patient’s ability to recover from stress. Patient characteristics including age, biological sex, body mass index (BMI), social deprivation index (SDI), and tobacco use, reported as current, former, or never smokers, were analyzed for their association to preoperative BRS scores. Linear regression models were applied to continuous variables. Differences in preoperative BRS scores by gender and tobacco use were assessed non-parametrically using an unpaired t-test and Kruskal-Wallis one-way analysis of variance with Tukey’s test for post-hoc analysis. Multiple linear regression was used to test the predictive effects of all variables. Pearson’s correlation test was used to analyze test-retest reliability of preoperative and longest follow-up BRS scores.

Results:

A total of 1131 patients with preoperative BRS scores were included. Age, BMI, and SDI were not appreciable predictive variables for preoperative BRS, demonstrating no statistical correlation (R2=0.004, R2 < 0.007, R2 < 0.001). Although differences in scores showed statistical significance between gender and tobacco use (p=0.004; p=0.039), the clinical relevance was negligible. The difference in preoperative BRS between gender was 0.11, and was not larger than 0.2 across smoking status. Average baseline BRS was 3.92±0.70 and average BRS at longest follow-up (471±174 days) was 3.87±0.74. Test-retest reliability of BRS showed good correlation (r =0.656, p-value < 0.001) (Figure 1). Overall, the fitted regression model was preoperative BRS = 4.0 + 0.005(age) – 0.012(BMI) – 0.0006(SDI) + 0.12(male = 1) – 0.19(current smoker = 1) – 0.11(former smoker = 1).

Conclusion:

Patient age, biological sex, body mass index, SDI, and tobacco use are not adequate predictive factors of patient preoperative BRS scores. Resilience is consistent over time, with little to no change at longest follow-up. These results suggest that resilience in the foot and ankle surgery population is an inherent quality that is not strongly associated with patient characteristics. The lack of association to variables such as body mass index, smoking status, and social deprivation suggest that resilience cannot be improved by addressing presumably modifiable patient characteristics. Work is underway studying the influence of patient counseling and education on patient resilience.