Clinical Presentation of Adults with Traumatic Orthopedic Injuries Enrolled in a Multisite Psychosocial Trial

Document Type : RESEARCH PAPER

Authors

1 1 Center for Health Outcomes and Interdisciplinary Research (CHOIR), Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA 2 Harvard Medical School, Boston, MA, USA

2 1 Center for Health Outcomes and Interdisciplinary Research (CHOIR), Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA 2 Harvard Medical School, Boston, MA, USA 3 Department of Sports Medicine, United States Olympic & Paralympic Committee, Colorado Springs, CO, USA

3 Center for Health Outcomes and Interdisciplinary Research (CHOIR), Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA

10.22038/abjs.2024.76953.3559

Abstract

Objectives: Traumatic orthopedic injuries are a top cause of hospital visits in the U.S. The Toolkit for 
Optimal Recovery (TOR) is a brief mind-body intervention that targets catastrophic thinking and pain 
anxiety following orthopedic injury. This study examines the baseline presentation of adults with 
traumatic orthopedic injuries who were enrolled in our recent multisite feasibility RCT of TOR versus 
usual care at four geographically distinct Level 1 trauma centers. We also examine whether patient 
presentation varies by site.
Methods: We recruited 181 adults (Mage=44.16, SD=16.5) from four Level I trauma centers located in the northeast 
(Site A; N=63), southwest (Site B; N=44), southeast (Site C; N=44), and southeast (Site D; N=30). At baseline, 
participants provided information about sociodemographic factors, pain and physical function, and physicians 
completed the Abbreviated Injury Scale (AIS). Descriptive statistics were used to characterize the sample, and oneway analysis of variance (ANOVA) and Chi-square tests were used to compare variables between sites.
Results: The majority of the sample (88.4%) sustained a fracture, and the mean AIS score was 2.31 (SD=0.55). 
Age, race, sex, gender, occupation, or marital status did not differ across sites (ps>.05). Over half (63%) of the 
sample was treated surgically, and 28.7% endorsed taking narcotic pain medications. More participants at Sites B 
(75%) and D (96.7%) received surgery than participants at Sites A (41%) and C (61.4%). More participants at Sites 
D and B reported narcotic usage than participants at Sites C and A. Participants at Site D demonstrated greater 
functional impairment than participants at the other sites.
Conclusion: Although sites were largely comparable, we did find key differences in surgical management, narcotic 
use, and functional disability which may have important implications for treatment response. This information will be 
used to iterate and refine TOR for a future multisite efficacy trial.
 Level of evidence: III

Keywords

Main Subjects

References

  1. Morris S, Lenihan B, Duddy L, O’Sullivan M. Outcome after musculoskeletal trauma treated in a regional hospital. J Trauma Acute Care Surg. 2000; 49(3):461. doi: 10.1097/00005373-200009000-00013.
  2. Busse JW, Heels-Ansdell D, Makosso-Kallyth S, et al. Patient coping and expectations predict recovery after major orthopaedic trauma. Br J Anaesth. 2019; 122(1):51-59. doi:10.1016/j.bja.2018.06.021.
  3. Clay FJ, Newstead SV, Watson WL, Ozanne-Smith J, Guy J, McClure RJ. Bio-psychosocial determinants of persistent pain 6 months after non-life-threatening acute orthopaedic trauma. J Pain. 2010; 11(5):420-430. doi:10.1016/j.jpain.2009.12.002.
  4. Dy CJ, Lane JM, Pan TJ, Parks ML, Lyman S. Racial and socioeconomic disparities in hip fracture care. J Bone Joint Surg Am. 2016; 98(10):858-865. doi:10.2106/JBJS.15.00676.
  5. Gupta A, Singh P, Badin D, et al. Racial disparities in lower extremity orthopaedic injuries presenting to U.S. emergency departments from 2010 to 2020. Trauma. 2023:14604086231186032. doi: 10.1177/14604086231186032.
  6. Quah C, Boulton C, Moran C. The influence of socioeconomic status on the incidence, outcome and mortality of fractures of the hip. J Bone Joint Surg Br. 2011; 93-B (6):801-805. doi:10.1302/0301-620X.93B6.24936.
  7. Sheridan E, Wiseman JM, Malik AT, et al. The role of sociodemographics in the occurrence of orthopaedic trauma. Injury. 2019; 50(7):1288-1292. doi:10.1016/j.injury.2019.05.018.
  8. Jacobs CA, Burnham JM, Jochimsen KN, Molina D, Hamilton DA, Duncan ST. Preoperative symptoms in femoroacetabular impingement patients are more related to mental health scores than the severity of labral tear or magnitude of bony deformity. J Arthroplasty. 2017; 32(12):3603-3606. doi: 10.1016/j.arth.2017.06.053.
  9. Jochimsen KN, Noehren B, Mattacola CG, Di Stasi S, Duncan ST, Jacobs C. Preoperative psychosocial factors and short-term pain and functional recovery after hip arthroscopy for femoroacetabular impingement syndrome. J Athl Train. 2021; 56(10):1064-1071. doi: 10.4085/1062-6050-139-20.
  10. Ravindra A, Barlow JD, Jones GL, Bishop JY. A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: psychosocial factors have a stronger association than structural factors. J Shoulder Elbow Surg. 2018; 27(10):1824-1829. doi:10.1016/j.jse.2018.06.019.
  11. Thoma LM, Rethorn TJ, Best TM, Flanigan DC, Schmitt LC. High kinesiophobia and pain catastrophizing in people with articular cartilage defects in the knee and associations with knee function. Knee. 2021; 28:17-24. doi:10.1016/j.knee.2020.10.020.
  12. Van Wyngaarden JJ, Archer KR, Spencer A, et al. Early pain catastrophizing exacerbates impaired limb loading and 6-minute walk test distance 12 months after lower extremity fracture. Phys Ther. 2021; 101(11):pzab194. doi:10.1093/ptj/pzab194.
  13. Harris IA, Young JM, Rae H, Jalaludin BB, Solomon MJ. Factors associated with back pain after physical injury: a survey of consecutive major trauma patients. Spine. 2007; 32(14):1561. doi:10.1097/BRS.0b013e318067dce8.
  14. Vranceanu AM, 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(3):e20. doi: 10.2106/JBJS.L.00479.
  15. Bakhshaie J, Doorley J, Reichman M, et al. Are surgeons’ tendencies to avoid discomfort associated with attitudes and beliefs toward patient psychosocial factors? Arch Bone Jt Surg. 2022; 10(7):611-620. doi:10.22038/abjs.2022.55134.2745.
  16. Bakhshaie J, Doorley J, Reichman M, et al. optimizing the implementation of a multisite feasibility trial of a mind–body program in acute orthopedic trauma. Transl Behav Med. 2022; 12(5):642-653. doi:10.1093/tbm/ibac004.
  17. Vranceanu AM, Bakhshaie J, Reichman M, et al. Understanding barriers and facilitators to implementation of psychosocial care within orthopedic trauma centers: a qualitative study with multidisciplinary stakeholders from geographically diverse settings. Implement Sci Commun. 2021; 2(1):102. doi:10.1186/s43058-021-00208-8.
  18. Vranceanu AM, Beks RB, Guitton TG, Janssen SJ, Ring D. How do orthopaedic surgeons address psychological aspects of illness? Arch Bone Jt Surg. 2017; 5(1):2-9.
  19. Vlaeyen JWS, Crombez G, Linton SJ. The fear-avoidance model of pain. PAIN. 2016; 157(8):1588. doi:10.1097/j.pain.0000000000000574.
  20. Vranceanu AM, Bakhshaie J, Reichman M, et al. A live video program to prevent chronic pain and disability in at-risk adults with acute orthopedic injuries (Toolkit for Optimal Recovery): protocol for a multisite feasibility study. JMIR Res Protoc. 2021; 10(4):e28155. doi:10.2196/28155.
  21. Vranceanu AM, Jacobs C, Lin A, et al. Results of a feasibility randomized controlled trial (RCT) of the Toolkit for Optimal Recovery (TOR): a live video program to prevent chronic pain in at-risk adults with orthopedic injuries. Pilot Feasibility Stud. 2019; 5(1):30. doi:10.1186/s40814-019-0416-7.
  22. Gonzalez JM, Alegría M, Prihoda TJ, Copeland LA, Zeber JE. How the relationship of attitudes toward mental health treatment and service use differs by age, gender, ethnicity/race and education. Soc Psychiatry Psychiatr Epidemiol. 2011; 46(1):45-57. doi:10.1007/s00127-009-0168-4.
  23. Chaudhary MA, von Keudell A, Bhulani N, et al. Prior prescription opioid use and its influence on opioid requirements after orthopedic trauma. J Surg Res. 2019; 238:29-34. doi:10.1016/j.jss.2019.01.016.
  24. Haupt E, Vincent HK, Harris A, et al. Pre-injury depression and anxiety in patients with orthopedic trauma and their treatment. Injury. 2018; 49(6):1079-1084. doi:10.1016/j.injury.2018.03.024.
  25. Holman JE, Stoddard GJ, Higgins TF. Rates of prescription opiate use before and after injury in patients with orthopaedic trauma and the risk factors for prolonged opiate use. J Bone Joint Surg Am. 2013; 95(12):1075-1080. doi:10.2106/JBJS.L.00619.
  26. Pierik JGJ, IJzerman MJ, Gaakeer MI, Vollenbroek-Hutten MMR, van Vugt AB, Doggen CJM. Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury. Eur J Pain. 2016; 20(5):711-722. doi:10.1002/ejp.796.
  27. Sullivan MJ, Adams H, Rhodenizer T, Stanish WD. A psychosocial risk factor–targeted intervention for the prevention of chronic pain and disability following whiplash injury. Phys Ther. 2006; 86(1):8-18. doi:10.1093/ptj/86.1.8.
  28. McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Res Manag. 2002; 7(1):517163. doi:10.1155/2002/517163.
  29. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. Pain. 2011; 152(10):2399-2404. doi:10.1016/j.pain.2011.07.005.
  30. Stone AA, Broderick JE, Junghaenel DU, Schneider S, Schwartz JE. PROMIS fatigue, pain intensity, pain interference, pain behavior, physical function, depression, anxiety, and anger scales demonstrate ecological validity. J Clin Epidemiol. 2016; 74:194-206. doi:10.1016/j.jclinepi.2015.08.029.
  31. Williams N. The Short Musculoskeletal Function Assessment (SMFA) questionnaire. Occup Med. 2016; 66(9):757. doi:10.1093/occmed/kqw140.
  32. Sullivan M, Bishop S, Pivik J. The Pain Catastrophizing Scale: development and validation. Psychol Assess. 1995; 7(4):524-532.
  33. McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Res Manag. 2002; 7(1):45-50. doi:10.1155/2002/517163.
  34. The Association for the Advancement of Automotive Medicine. Abbreviated Injury Scale (AIS) 2015. Available at: https://www.aaam.org/.2016.
  35. R Core Team. R: A language and environment for statistical computing. Global Core Biodata Resource (GBIF). Available at: https://www.gbif.org/tool/81287/r-a-language-and-environment-for-statistical-computing. Accessed February 10, 2015.
  36. J.J. Allaire. RStudio: Integrated Development Environment for R. Available at: https://www.r-project.org/conferences/useR-2011/abstracts/180111-allairejj.pdf.
  37. Cohen J, eds. Statistical Power Analysis for the Behavioral Sciences. 2st ed. Department of Psychology, New York University, New York. Lawrence Erlbaum Associates, Publishers; 1988.
  38. Maher JM, Markey JC, Ebert-May D. The other half of the story: effect size analysis in quantitative research. CBE Life Sci Educ. 2013; 12(3):345-351. doi:10.1187/cbe.13-04-0082.
  39. Ring D. Recovery after musculoskeletal injury: mental and social health. J Orthop Trauma. 2022; 36:S1. doi:10.1097/BOT.0000000000002447.
  40. Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain among Adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018; 67(36):1001-1006. doi:10.15585/mmwr.mm6736a2.
  41. Archer KR, MacKenzie EJ, Bosse MJ, Pollak AN, Riley LH III. Factors associated with surgeon referral for physical therapy in patients with traumatic lower-extremity injury: results of a national survey of orthopedic trauma surgeons. Phys Ther. 2009; 89(9):893-905. doi:10.2522/ptj.20080321.
  42. Goodin BR, McGuire L, Allshouse M, et al. Associations between catastrophizing and endogenous pain-inhibitory processes: sex differences. J Pain. 2009; 10(2):180-190. doi:10.1016/j.jpain.2008.08.012.
  43. Mogil JS. Qualitative sex differences in pain processing: emerging evidence of a biased literature. Nat Rev Neurosci. 2020; 21(7):353-365. doi:10.1038/s41583-020-0310-6.
  44. Hermanussen HH, Menendez ME, Chen NC, Ring D, Vranceanu AM. Predictors of upper-extremity physical function in older adults. Arch Bone Jt Surg. 2016; 4(4):359-365.
The Archives of Bone and Joint Surgery
Volume 12, Issue 12
December 2024
Pages 826-834

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History

  • Receive Date: 29 December 2023
  • Revise Date: 28 August 2024
  • Accept Date: 16 September 2024

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