- Email: [email protected]
Psychological factors and recovery from trauma
ARTICLE IN PRESS
JID: JINJ
[m5G;October 29, 2019;20:18]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Psychological factors and recovery from trauma Christine Schemitsch, Aaron Nauth∗ St. Michael’s Hospital, 55 Queen Street East, Suite 800, Toronto, Ontario M5C 1R6, Canada
a r t i c l e
i n f o
Article history: Accepted 22 October 2019 Available online xxx Keywords: Orthopaedic trauma Biopsychosocial model
a b s t r a c t Recent research has identified a high prevalence of psychological illnesses in patients who have sustained orthopaedic trauma. Depressive symptoms in this patient population have been reported to range from 13% to as high as 56%. Moreover, symptoms of depression, catastrophic thinking, and post-traumatic stress disorder (PTSD), have been consistently shown to negatively impact patient outcomes following treatment for their traumatic injuries. Specifically, patients with higher levels of psychosocial dysfunction have shown increased levels of pain, disability, and complications throughout their recovery. However, current research in orthopaedic trauma continues to be substantially focused on the physical and technical factors involved in the treatment of orthopaedic injuries. More research which applies the “biopsychosocial model” of health and evaluates the significant impact of psychological and social factors on recovery from trauma is needed. In particular, investigation which evaluates effective screening strategies and interventions to treat psychosocial dysfunction during recovery from trauma is highly desirable. This article reviews the current state of knowledge in this area and suggests future directions for research. © 2019 Published by Elsevier Ltd.
Introduction Significant advancements have been made in the surgical management of orthopaedic trauma patients [1,2]. However, high rates of pain and disability following musculoskeletal injury remain prevalent. Orthopaedic trauma research in the past has been substantially focused on physical and technical factors involved in the treatment of these injuries. These types of investigations correspond to the traditional biomedical model, which reduces the cause of illness and disease to biological and mechanical disruptions within the body [3,4]. However, there is an increasing body of literature that points to the substantial importance of psychosocial factors in the recovery from trauma and musculoskeletal injury. Such investigations recognize the “biopsychosocial model” of health (Fig. 1) and have sought to evaluate the significant impact of psychological and social factors on outcomes and recovery from trauma. While the biopsychosocial model was first proposed by George Engel in 1977, its uptake in orthopaedic practice and research has been slow [3,4]. Prevalence of psychological disorders and association with outcome Psychological disorders in patients who have sustained orthopaedic traumatic injuries are common. Symptoms of depres∗
Corresponding author. E-mail address: [email protected] (A. Nauth).
sion, anxiety, and post-traumatic stress disorder (PTSD) in orthopaedic trauma patients have been reported to range between 13–56% [5–19], 5–35% [5–9], and 15–51% [10–15,20], respectively. Several studies have established an association between these psychological factors and worse post-operative outcomes. Vranceanu et al. assessed symptoms of depression, PTSD, catastrophic thinking and pain anxiety in patients 1–2 months and 5–8 months after musculoskeletal trauma [10]. At 1–2 months, 23% (35/152) of patients screened positive for depressive symptoms, while 28% (43/152) screened positive for a diagnosis of PTSD. The high rate of depressive symptoms persisted at 5–8 months after the trauma (21%, 29/136), however, the rate of PTSD symptoms decreased to 18% (25/136). In this study, a higher level of catastrophic thinking at 1–2 months was a significant predictor of increased disability and pain at later follow-up, whereas depression and PTSD were not predictive of worse outcomes. A similar study was conducted by Nota et al. on trauma patients in the Netherlands [11]. The authors reported that at 1–2 months after musculoskeletal trauma, 20% (13/65) of patients met the threshold for a diagnosis of depression, while 15% (10/65) met the threshold for a diagnosis of PTSD. Symptoms of depression increased to 34% at 5–8 months after the injury, while symptoms of PTSD were maintained at 15%. In this study also, higher levels of catastrophic thinking at 1–2 months was a significant predictor of increased disability at later follow-up. Crichlow et al., assessed symptoms of depression three to twelve months after injury using the Beck Depression Inventory (BDI) in 161 patients [16]. Forty-five percent of patients met the criteria for moderate to severe symptoms of depression. The au-
https://doi.org/10.1016/j.injury.2019.10.081 0020-1383/© 2019 Published by Elsevier Ltd.
Please cite this article as: C. Schemitsch and A. Nauth, Psychological factors and recovery from trauma, Injury, https://doi.org/10.1016/j. injury.2019.10.081
JID: JINJ
ARTICLE IN PRESS
2
[m5G;October 29, 2019;20:18]
C. Schemitsch and A. Nauth / Injury xxx (xxxx) xxx
Fig. 1. Biopsychosocial model of health.
thors also conducted a secondary analysis of BDI scores with questions relating to physical symptoms removed. Twenty-six percent of the participants in the study still demonstrated symptoms of moderate to severe depression. A significant correlation was found between physical function and symptoms of depression. Specifically, higher scores on the BDI (indicative of higher levels of symptoms of depression) were associated with worse functional outcomes. Archer et al. (2015) reported on a series of 134 patients who received surgical treatment for a lower extremity fracture [18]. At four weeks post-surgery, 21% of patients (28/134) reported moderate to severe levels of pain catastrophization, 65% (87/134) reported a high fear of movement, and 38% (51/134) reported symptoms of depression. Higher levels of pain catastrophization and depressive symptoms were both associated with pain intensity and pain interference at 1 year. Depressive symptoms were also associated with worse physical health at one year. In a series of 101 orthopaedic trauma patients, Vincent et al. reported that at 12 weeks post-discharge from hospital, 20.9% of patients had symptoms of moderate-to-severe depression, and 35.3% of patients had symptoms of anxiety [5]. Moreover, the authors found that patients who screened positive symptoms of depression at 12 weeks had a higher rate of unexpected adverse events requiring readmission (57.1% versus 13.4%, P = 0.001). A cross sectional survey of patients admitted to hospital for the treatment of a fracture was conducted by McCrabb et al. to determine the prevalence of tobacco use, and symptoms of anxiety and depression [7]. Overall, 21.8% of patients were identified as smokers, while 12.9% and 12.4% of patients met the threshold for symptoms of depression and anxiety, respectively. The prevalence of anxiety and depression was significantly higher in patients who smoked than in patients who did not (19% vs. 11.3%, P = 0.008; 19.1% vs. 10.7%, P = 0.003). Pre-existing psychological illnesses are also highly prevalent in trauma patients [6]. Weinberg et al. investigated the prevalence of psychological illnesses in patients who had sustained a femoral or axial skeleton fracture and were treated at a level I trauma centre [6]. A pre-existing psychiatric disorder was present in 39.2% of patients (130/332) enrolled in the study. Depression (22.3%), substance abuse (16.9%), and generalized anxiety disorder (4.8%) were the three most prevalent psychiatric illnesses among patients in the study. In that study, depression was found to be an independent predictor of increased post-operative complications (odds ratio = 2.956, 95% CI = 1.502 to 5.816). Orthopaedic surgeons perceptions of psychological factors While orthopaedic surgeons believe they are adept at recognizing psychological signs and symptoms in their patients, for various
reasons, appropriate referrals for management of these symptoms are often not made. In a survey completed by 350 orthopaedic surgeons, Vranceanu et al. reported that 90% (314/350) of surgeons were somewhat or very likely to notice psychological illnesses in their patients. Only 60%, however, reported they were somewhat or very likely to refer their patients for treatment [21]. The greatest barrier for referring patients was a lack of time, followed by the stigma associated with psychological factors, and being unsure of how to refer patients. Despite these barriers, providing surgeons with training/education on available resources has been shown to improve their confidence and capability in managing psychological factors in their patients [1]. Furthermore, Vranceanu et al. reported that surgeon’s attitudes were fairly neutral towards the practice of formally screening psychological illnesses in patients [21]. The use of standardized questionnaires was the least common method to screen for psychological illnesses (24%, 85/350). The majority of surgeons relied on the patients’ medical record (57%, 201/350) or the interview with the patient (81%, 282/350). As noted by the authors, this finding is particularly interesting as standardized questionnaires can be an effective and accurate method to quickly screen patients for psychological illnesses. This literature highlights an important theme in that orthopaedic surgeons may not be adequately screening and/or treating psychological disorders in their trauma patient populations, despite their high prevalence and potential impact on outcomes. Treatment interventions Despite the high rate of psychological disorders in this patient population, these conditions are often untreated or undertreated in a large portion of patients. Low rates of treatment for psychological conditions were reported by the LEAP study group [8]. In that series of patients who had sustained a severe lowerlimb injury, 48% screened positive for a psychological disorder at 3 months post-injury and 42% screened positive at 24 months. At 3 months, only 12% of these patients reported using any mental health services, and by two years this number had only increased to 22%. The implementation of interventional programs may help patients to manage psychosocial factors and improve their outcomes during recovery. One such program is the Trauma Survivors Network (TSN) which was developed by the American Trauma Society [2,22]. The TSN is comprised of four interventions: (1) peer support, (2) self-management, (3) information and resources, and (4) provider training [2]. These interventions aim to help patients and their families address their psychosocial needs during recovery from traumatic injury. A study by Castillo et al. assessed the effectiveness of the Trauma Survivors Network following its implementation at a level I trauma centre [2]. A group of 125 patients were assessed prior to the implementation of the TSN program and 126 patients were assessed after the implementation. The treatment group had 49% lower odds of depression, however, this finding was borderline in terms of statistical significance, with a p-value of 0.05. Overall, the authors found that use of the TSN resources was low among the study participants, with use ranging from 3% to 27% for the different aspects of the program (3% of patients attended the self-management course, 6% of patients attended a support group, 10% met with a peer visitor, 17% visited the TSN website, and 27% of the patients received the TSN handbook). Of the patients with follow-up available, only 47% had used one or more of the resources. A preliminary randomized control trial (RCT) was conducted by Vranceanu et al. to assess the acceptability, feasibility and efficacy of implementing a biopsychosocial intervention in patients who had sustained an acute musculoskeletal trauma [23]. Patients were randomized to either cognitive behavioural (CB) and relaxation
Please cite this article as: C. Schemitsch and A. Nauth, Psychological factors and recovery from trauma, Injury, https://doi.org/10.1016/j. injury.2019.10.081
JID: JINJ
ARTICLE IN PRESS
[m5G;October 29, 2019;20:18]
C. Schemitsch and A. Nauth / Injury xxx (xxxx) xxx
response (RR) strategies or standard of care. While the sample size of this preliminary RCT was quite small (48 patients), the authors noted significant differences between the two groups for pain with activity, disability, and psychological factors at 4–6 weeks after the intervention. Additionally, 86% (24/28) of the patients randomized to the CBRR group completed the full intervention, which was comprised of 4–6 sessions, indicating a high patient compliance with the program. In caring for orthopaedic trauma patients, it is essential that surgeons are aware that symptoms of depression, anxiety and PTSD are common in this patient population and can affect treatment outcomes. Surgeons and institutions should identify processes to integrate effective screening tools (i.e., validated questionnaires) into current practice, in addition to providing appropriate referrals and resources to these patients. This would allow for early identification of those patients who may benefit from psychosocial interventions, and potentially improve treatment outcomes. Surgeons should be aware of any programs, such as the Trauma Survivors Network, that may already be available at their hospital, and make these programs readily available to their patients. Conclusion High rates of psychological disorders are evident in patients who have sustained orthopaedic trauma injuries. In addition, these factors are strongly associated with increased disability, pain and complications following trauma. Despite this, orthopaedic trauma research continues to be substantially focused on physical and technical factors. The research highlighted here suggests that movement towards a more holistic approach that incorporates the biopsychosocial model is warranted. More research is needed in this area, with a particular focus on efficient screening and identification of psychosocial dysfunction in patients recovering from orthopaedic trauma, as well as active investigation of potential interventions that can be employed to treat patients when psychosocial dysfunction is identified following orthopaedic trauma. Ultimately, such research will better equip orthopaedic trauma surgeons with concrete tools to identify and treat psychosocial dysfunction in their patients, with a view to improving outcomes. Declaration of Competing Interest None. References [1] Wegener ST, Carroll EA, Gary JL, McKinley TO, O’Toole RV, Sietsema DL, et al. Trauma collaborative intervention: effect on surgeon confidence in managing psychosocial complications after orthopaedic trauma. J Orthop Trauma 2017;31(8):427–33.
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[2] Castillo RC, Wegener ST, Zadnik Newell M, Carlini AR, Bradford AN, Heins SE, et al. Improving outcomes at level I trauma centers: an early evaluation of the trauma survivors network. J Trauma Acute Care Surg 2013;74(6):1534–40. [3] Ayers DC, Franklin PD, Ring DC. The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues. J Bone Joint Surg Am 2013;95(21):e165. [4] Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. J Bone Joint Surg Am 2009;91(8):2014–18. [5] Vincent HK, Hagen JE, Zdziarski-Horodyski LA, Patrick M, Sadasiva KK, Guenther R, et al. Patient-reported outcomes measurement information system outcome measures and mental health in orthopaedic trauma patients during early recovery. J Orthop Trauma 2018;32(9):467–73. [6] Weinberg DS, Narayanan AS, Boden KA, Breslin MA, Vallier HA. Psychiatric illness is common among patients with orthopaedic polytrauma and is linked with poor outcomes. J Bone Joint Surg Am 2016;98:341–8. [7] McCrabb S, Baker AL, Balogh ZJ, Lott N, Palazzi K, Naylor J, et al. Comorbid tobacco and other substance use and symptoms of anxiety and depression among hospitalized orthopaedic trauma patients. BMC Psychiatry 2019;19(28):1–9. [8] McCarthy ML, MacKenzie EH, Edwin D, Bosse MJ, Castillo RC, Starr AL.E.A.P. Study Group. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am 2003;85(9):1689–97. [9] Bhandari M, Busse JW, Hanson BP, Leece P, Ayeni OR, Schemitsch EH. Psychological distress and quality of life after orthopaedic trauma: an observational study. Can J Surg 2008;51(1):16–22. [10] Vranceanu A, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am 2014;96(1–6):e20. [11] Nota S, Bot AGJ, Ring D, Kloen P. Disability and depression after orthopaedic trauma. Injury 2015;46:207–12. [12] Archer KR, Heins SE, Abraham CM, Obremskey WT, Wegener ST, Castillo RC. Clinical significance of pain at hospital discharge following traumatic orthopedic injury. Clin J Pain 2016;32(3):196–202. [13] Roden-Foreman K, Solis J, Jones A, Bennet M, Roden-foreman JW, Rainey EE, et al. Prospective evaluation of posttraumatic stress disorder and depression in orthopaedic injury patients with and without concomitant traumatic brain injury. J Orthop Trauma 2017;31(9):e275–80. [14] Muscatelli S, Spur H, O’Hara NN, O’Hara LM, Sprague SA, Slobogean GP. Prevalence of depression and posttraumatic stress disorder after acute orthopaedic trauma: a systematic review and meta-analysis. J Orthop Trauma 2017;31(1):47–55. [15] Ponsford J, Hill B, Karamirsios M, Bahar-Fuchs A. Factors influencing outcome after orthopaedic trauma. J Trauma 20 08;64(4):10 01–9. [16] Crichlow RJ, Andres PL, Morrison SM, Haley SM, Vrahas MS. Depression in orthopaedic trauma patients – prevalence and severity. J Bone Joint Surg 2006;88(9):1927–33. [17] Becher S, Smith M, Ziran B. Orthopaedic trauma patients and depression: a prospective cohort. J Orthop Trauma 2014;28(10):e242–6. [18] Archer KR, Abraham CM, Obremsky WT. Psychosocial factors predict pain and physical health after lower extremity trauma. Clin Orthop Relat Res 2015;473:3519–26. [19] Gitajn I, Titus A, Mastrangelo S, Ali S, Sparks M, Jevsevar D. Psychiatric illness is common in elderly fracture patients. J Orthop Trauma 2019;33(3):149–54. [20] Starr AJ, Smith WR, Frawley WH, Borer DS, Morgan SJ, Reinert CM, et al. Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am 2004;86-A(6):1115–21. [21] Vranceanu A, Beks RB, Guitton TG, Janssem SJ, Ring D. How do orthopaedic surgeons address psychological aspects of illness? Arch Bone Jt Surg 2017;5(1):2–9. [22] Wegener AT, Pollak AN, Frey KP, Hymes RA, Archer KR, Jones CB, et al. The trauma collaborative care study (TCCS). J Orthop Trauma 2017;31(4):S78–87. [23] Vranceanu A, Hageman M, Strooker J, Meulen D, Vrahas M, Ring D. A preliminary RCT of a mind body skills based intervention addressing mood and coping strategies in patients with acute orthopaedic trauma. Injury 2015;46(4):552–7.
Please cite this article as: C. Schemitsch and A. Nauth, Psychological factors and recovery from trauma, Injury, https://doi.org/10.1016/j. injury.2019.10.081
JID: JINJ
[m5G;October 29, 2019;20:18]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Psychological factors and recovery from trauma Christine Schemitsch, Aaron Nauth∗ St. Michael’s Hospital, 55 Queen Street East, Suite 800, Toronto, Ontario M5C 1R6, Canada
a r t i c l e
i n f o
Article history: Accepted 22 October 2019 Available online xxx Keywords: Orthopaedic trauma Biopsychosocial model
a b s t r a c t Recent research has identified a high prevalence of psychological illnesses in patients who have sustained orthopaedic trauma. Depressive symptoms in this patient population have been reported to range from 13% to as high as 56%. Moreover, symptoms of depression, catastrophic thinking, and post-traumatic stress disorder (PTSD), have been consistently shown to negatively impact patient outcomes following treatment for their traumatic injuries. Specifically, patients with higher levels of psychosocial dysfunction have shown increased levels of pain, disability, and complications throughout their recovery. However, current research in orthopaedic trauma continues to be substantially focused on the physical and technical factors involved in the treatment of orthopaedic injuries. More research which applies the “biopsychosocial model” of health and evaluates the significant impact of psychological and social factors on recovery from trauma is needed. In particular, investigation which evaluates effective screening strategies and interventions to treat psychosocial dysfunction during recovery from trauma is highly desirable. This article reviews the current state of knowledge in this area and suggests future directions for research. © 2019 Published by Elsevier Ltd.
Introduction Significant advancements have been made in the surgical management of orthopaedic trauma patients [1,2]. However, high rates of pain and disability following musculoskeletal injury remain prevalent. Orthopaedic trauma research in the past has been substantially focused on physical and technical factors involved in the treatment of these injuries. These types of investigations correspond to the traditional biomedical model, which reduces the cause of illness and disease to biological and mechanical disruptions within the body [3,4]. However, there is an increasing body of literature that points to the substantial importance of psychosocial factors in the recovery from trauma and musculoskeletal injury. Such investigations recognize the “biopsychosocial model” of health (Fig. 1) and have sought to evaluate the significant impact of psychological and social factors on outcomes and recovery from trauma. While the biopsychosocial model was first proposed by George Engel in 1977, its uptake in orthopaedic practice and research has been slow [3,4]. Prevalence of psychological disorders and association with outcome Psychological disorders in patients who have sustained orthopaedic traumatic injuries are common. Symptoms of depres∗
Corresponding author. E-mail address: [email protected] (A. Nauth).
sion, anxiety, and post-traumatic stress disorder (PTSD) in orthopaedic trauma patients have been reported to range between 13–56% [5–19], 5–35% [5–9], and 15–51% [10–15,20], respectively. Several studies have established an association between these psychological factors and worse post-operative outcomes. Vranceanu et al. assessed symptoms of depression, PTSD, catastrophic thinking and pain anxiety in patients 1–2 months and 5–8 months after musculoskeletal trauma [10]. At 1–2 months, 23% (35/152) of patients screened positive for depressive symptoms, while 28% (43/152) screened positive for a diagnosis of PTSD. The high rate of depressive symptoms persisted at 5–8 months after the trauma (21%, 29/136), however, the rate of PTSD symptoms decreased to 18% (25/136). In this study, a higher level of catastrophic thinking at 1–2 months was a significant predictor of increased disability and pain at later follow-up, whereas depression and PTSD were not predictive of worse outcomes. A similar study was conducted by Nota et al. on trauma patients in the Netherlands [11]. The authors reported that at 1–2 months after musculoskeletal trauma, 20% (13/65) of patients met the threshold for a diagnosis of depression, while 15% (10/65) met the threshold for a diagnosis of PTSD. Symptoms of depression increased to 34% at 5–8 months after the injury, while symptoms of PTSD were maintained at 15%. In this study also, higher levels of catastrophic thinking at 1–2 months was a significant predictor of increased disability at later follow-up. Crichlow et al., assessed symptoms of depression three to twelve months after injury using the Beck Depression Inventory (BDI) in 161 patients [16]. Forty-five percent of patients met the criteria for moderate to severe symptoms of depression. The au-
https://doi.org/10.1016/j.injury.2019.10.081 0020-1383/© 2019 Published by Elsevier Ltd.
Please cite this article as: C. Schemitsch and A. Nauth, Psychological factors and recovery from trauma, Injury, https://doi.org/10.1016/j. injury.2019.10.081
JID: JINJ
ARTICLE IN PRESS
2
[m5G;October 29, 2019;20:18]
C. Schemitsch and A. Nauth / Injury xxx (xxxx) xxx
Fig. 1. Biopsychosocial model of health.
thors also conducted a secondary analysis of BDI scores with questions relating to physical symptoms removed. Twenty-six percent of the participants in the study still demonstrated symptoms of moderate to severe depression. A significant correlation was found between physical function and symptoms of depression. Specifically, higher scores on the BDI (indicative of higher levels of symptoms of depression) were associated with worse functional outcomes. Archer et al. (2015) reported on a series of 134 patients who received surgical treatment for a lower extremity fracture [18]. At four weeks post-surgery, 21% of patients (28/134) reported moderate to severe levels of pain catastrophization, 65% (87/134) reported a high fear of movement, and 38% (51/134) reported symptoms of depression. Higher levels of pain catastrophization and depressive symptoms were both associated with pain intensity and pain interference at 1 year. Depressive symptoms were also associated with worse physical health at one year. In a series of 101 orthopaedic trauma patients, Vincent et al. reported that at 12 weeks post-discharge from hospital, 20.9% of patients had symptoms of moderate-to-severe depression, and 35.3% of patients had symptoms of anxiety [5]. Moreover, the authors found that patients who screened positive symptoms of depression at 12 weeks had a higher rate of unexpected adverse events requiring readmission (57.1% versus 13.4%, P = 0.001). A cross sectional survey of patients admitted to hospital for the treatment of a fracture was conducted by McCrabb et al. to determine the prevalence of tobacco use, and symptoms of anxiety and depression [7]. Overall, 21.8% of patients were identified as smokers, while 12.9% and 12.4% of patients met the threshold for symptoms of depression and anxiety, respectively. The prevalence of anxiety and depression was significantly higher in patients who smoked than in patients who did not (19% vs. 11.3%, P = 0.008; 19.1% vs. 10.7%, P = 0.003). Pre-existing psychological illnesses are also highly prevalent in trauma patients [6]. Weinberg et al. investigated the prevalence of psychological illnesses in patients who had sustained a femoral or axial skeleton fracture and were treated at a level I trauma centre [6]. A pre-existing psychiatric disorder was present in 39.2% of patients (130/332) enrolled in the study. Depression (22.3%), substance abuse (16.9%), and generalized anxiety disorder (4.8%) were the three most prevalent psychiatric illnesses among patients in the study. In that study, depression was found to be an independent predictor of increased post-operative complications (odds ratio = 2.956, 95% CI = 1.502 to 5.816). Orthopaedic surgeons perceptions of psychological factors While orthopaedic surgeons believe they are adept at recognizing psychological signs and symptoms in their patients, for various
reasons, appropriate referrals for management of these symptoms are often not made. In a survey completed by 350 orthopaedic surgeons, Vranceanu et al. reported that 90% (314/350) of surgeons were somewhat or very likely to notice psychological illnesses in their patients. Only 60%, however, reported they were somewhat or very likely to refer their patients for treatment [21]. The greatest barrier for referring patients was a lack of time, followed by the stigma associated with psychological factors, and being unsure of how to refer patients. Despite these barriers, providing surgeons with training/education on available resources has been shown to improve their confidence and capability in managing psychological factors in their patients [1]. Furthermore, Vranceanu et al. reported that surgeon’s attitudes were fairly neutral towards the practice of formally screening psychological illnesses in patients [21]. The use of standardized questionnaires was the least common method to screen for psychological illnesses (24%, 85/350). The majority of surgeons relied on the patients’ medical record (57%, 201/350) or the interview with the patient (81%, 282/350). As noted by the authors, this finding is particularly interesting as standardized questionnaires can be an effective and accurate method to quickly screen patients for psychological illnesses. This literature highlights an important theme in that orthopaedic surgeons may not be adequately screening and/or treating psychological disorders in their trauma patient populations, despite their high prevalence and potential impact on outcomes. Treatment interventions Despite the high rate of psychological disorders in this patient population, these conditions are often untreated or undertreated in a large portion of patients. Low rates of treatment for psychological conditions were reported by the LEAP study group [8]. In that series of patients who had sustained a severe lowerlimb injury, 48% screened positive for a psychological disorder at 3 months post-injury and 42% screened positive at 24 months. At 3 months, only 12% of these patients reported using any mental health services, and by two years this number had only increased to 22%. The implementation of interventional programs may help patients to manage psychosocial factors and improve their outcomes during recovery. One such program is the Trauma Survivors Network (TSN) which was developed by the American Trauma Society [2,22]. The TSN is comprised of four interventions: (1) peer support, (2) self-management, (3) information and resources, and (4) provider training [2]. These interventions aim to help patients and their families address their psychosocial needs during recovery from traumatic injury. A study by Castillo et al. assessed the effectiveness of the Trauma Survivors Network following its implementation at a level I trauma centre [2]. A group of 125 patients were assessed prior to the implementation of the TSN program and 126 patients were assessed after the implementation. The treatment group had 49% lower odds of depression, however, this finding was borderline in terms of statistical significance, with a p-value of 0.05. Overall, the authors found that use of the TSN resources was low among the study participants, with use ranging from 3% to 27% for the different aspects of the program (3% of patients attended the self-management course, 6% of patients attended a support group, 10% met with a peer visitor, 17% visited the TSN website, and 27% of the patients received the TSN handbook). Of the patients with follow-up available, only 47% had used one or more of the resources. A preliminary randomized control trial (RCT) was conducted by Vranceanu et al. to assess the acceptability, feasibility and efficacy of implementing a biopsychosocial intervention in patients who had sustained an acute musculoskeletal trauma [23]. Patients were randomized to either cognitive behavioural (CB) and relaxation
Please cite this article as: C. Schemitsch and A. Nauth, Psychological factors and recovery from trauma, Injury, https://doi.org/10.1016/j. injury.2019.10.081
JID: JINJ
ARTICLE IN PRESS
[m5G;October 29, 2019;20:18]
C. Schemitsch and A. Nauth / Injury xxx (xxxx) xxx
response (RR) strategies or standard of care. While the sample size of this preliminary RCT was quite small (48 patients), the authors noted significant differences between the two groups for pain with activity, disability, and psychological factors at 4–6 weeks after the intervention. Additionally, 86% (24/28) of the patients randomized to the CBRR group completed the full intervention, which was comprised of 4–6 sessions, indicating a high patient compliance with the program. In caring for orthopaedic trauma patients, it is essential that surgeons are aware that symptoms of depression, anxiety and PTSD are common in this patient population and can affect treatment outcomes. Surgeons and institutions should identify processes to integrate effective screening tools (i.e., validated questionnaires) into current practice, in addition to providing appropriate referrals and resources to these patients. This would allow for early identification of those patients who may benefit from psychosocial interventions, and potentially improve treatment outcomes. Surgeons should be aware of any programs, such as the Trauma Survivors Network, that may already be available at their hospital, and make these programs readily available to their patients. Conclusion High rates of psychological disorders are evident in patients who have sustained orthopaedic trauma injuries. In addition, these factors are strongly associated with increased disability, pain and complications following trauma. Despite this, orthopaedic trauma research continues to be substantially focused on physical and technical factors. The research highlighted here suggests that movement towards a more holistic approach that incorporates the biopsychosocial model is warranted. More research is needed in this area, with a particular focus on efficient screening and identification of psychosocial dysfunction in patients recovering from orthopaedic trauma, as well as active investigation of potential interventions that can be employed to treat patients when psychosocial dysfunction is identified following orthopaedic trauma. Ultimately, such research will better equip orthopaedic trauma surgeons with concrete tools to identify and treat psychosocial dysfunction in their patients, with a view to improving outcomes. Declaration of Competing Interest None. References [1] Wegener ST, Carroll EA, Gary JL, McKinley TO, O’Toole RV, Sietsema DL, et al. Trauma collaborative intervention: effect on surgeon confidence in managing psychosocial complications after orthopaedic trauma. J Orthop Trauma 2017;31(8):427–33.
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Please cite this article as: C. Schemitsch and A. Nauth, Psychological factors and recovery from trauma, Injury, https://doi.org/10.1016/j. injury.2019.10.081