Comorbidity of Musculoskeletal Injury Pain and PTSD
Each year, the Federal Government spends an estimated $12.6 billion on injury-related medical costs.1 In spite of advances in trauma care, people who experience injury are often unable to return-to-work. When added to medical costs, death and disability benefits, monies paid by insurance companies, and other private sources, lost wages and lost productivity bring the costs of injury to $224 billion per year.1 Orthopaedic injuries are especially problematic because they often require prolonged treatment and frequently result in long-term disability.2,3 Studies also demonstrate a high incidence of emotional distress following such general orthopaedic trauma4-11 and a more recent investigation indicated the incidence of stress-related symptoms is even higher in the orthopaedic population.12 The purpose the study by Starr and colleagues was to determine the prevalence of emotional distress among orthopaedic trauma patients seen in clinic following injury and to examine whether injury or demographic variables were predictive of such emotional distress. This multi-center effort involved testing 580 orthopaedic trauma patients, with injury and demographic information collected for all study patients. Demographic and injury data were tested to evaluate if any were statistically associated with the presence of significant emotional distress. Findings revealed that patients with high levels of emotional distress had significantly higher Injury Severity Scores (p=.04), higher sum of Extremity Abbreviated Injury Scores (p=.05), and were further out from injury than those without high emotional distress. The study also clearly revealed that emotional distress is common after orthopaedic trauma and led the investigators to plan further research to evaluate whether psychological treatment can prevent high levels of such distress.
A subsequent investigation by Starr and colleagues evaluated emotional distress associated with severe lower limb injury. Data for this study were collected as part of a larger study, the Lower Extremity Assessment Project (LEAP), designed to compare the long term outcomes of patients who sustained severe lower extremity trauma treated by limb reconstruction or amputation. Patients were enrolled in LEAP during their initial hospitalization and followed over a two-year period to assess their physical and psychosocial health. Earlier publications of LEAP study results showed that outcomes in many such patients were poor,2 with only approximately 50% returning to work at two years. For the study of emotional distress, patients completed the Brief Symptom Inventory (BSI) to assess emotional symptoms, and the Sickness Impact Profile (SIP) to assess overall outcome. The research showed that 42% of patients screened positive for a likely emotional disorder two years after injury, and that BSI scores were strongly associated with SIP scores, especially SIP physical function scores. This raised the possibility of a link between emotional outcome and functional outcome, and demonstrated the need for future research to focus on interventions that will address and reduce the emotional distress of patients who sustain orthopaedic injuries.
Indeed, patients are often found to develop other comorbid psychiatric disorders, including major depressive disorder, pain disorders, substance abuse disorders, or anxiety disorders following traumatic accidents.5,6,8,13,14 Emotional distress also affects patients’ reports of physical complaints15-19 and is among the variables that are most predictive of functional outcome following injury. In a retrospective study examining persons with moderate traumatic injury, emotional distress was found to contribute more to perceived general health than did injury severity or the degree of physical functioning.6 Furthermore, a prospective study examining emotional distress, problem drinking, and functional outcome after injury found that, at one year post-injury, emotional distress was the strongest predictor of an adverse outcome.11 Post-traumatic emotional illnesses may explain why some trauma patients report poor outcomes, even when traditional “objective” variables—such as wound healing or limb function—would lead a clinician to expect good results.
Given the impact of emotional distress on outcome after orthopaedic injury trauma, it seems logical that emotional treatment might improve patients’ overall functioning. The costs of injury are enormous. Treatments which improve emotional outcome, even if only slightly, should reduce the economic impact of trauma, as well as improve functional outcomes.20 The need for such treatments is reflected in The Centers for Disease Comparison Injury Research Agenda,21 which states that a priority in acute care research is to “…develop and evaluate protocols that provide onsite interventions in acute care settings, or linkages to off-site services, for patients at risk of injury or psychosocial problems following injury.”
This need is not only important for the civilian population, but also for the military population. Indeed, historically, during the course of military conflicts, orthopaedic extremity injuries account for the majority of injuries treated in military medical treatment facilities. As the characteristics of war change, and advances in orthopaedic injury treatment continue to develop, it is increasingly more likely that soldiers’ lives will be saved, though many will require extensive procedures and treatments before they can return to duty or civilian life. Each year, the Armed Forces experience significant costs associated with losing service members to medical retirement. It can cost over $31,000 to recruit and provide advanced training to one person designated to replace a single soldier lost to a medical board, and it can cost an additional $250,000 per person to cover lifetime disability benefits! These injuries are also often prodromal stages to even more serious diseases such as osteoporosis, post-traumatic arthritis, peripheral neuropathies, etc.—as well as psychiatric disorders/disease. New treatment methods would increase more rapid return-to-work and work productivity after appropriate orthopaedic treatment for extremity injuries. With the recent military deployments in Iraq and Afghanistan, the prevalence of these disorders is increasing. In fact, recent battle casualty data from Operation Iraqi Freedom indicate that, with increased use of body armor in combat, orthopaedic extremity injuries are the most common injuries resulting in hospitalization.22 A recent study published in 2006 on wounding patterns for U.S. marines and sailors serving in Iraq found that upper and lower extremity injuries accounted for almost 70% of all injuries.23 Significant emotional distress has also been found in battle-injured soldiers.24
“...a clinician’s understanding of patients’ past and current history of traumatic events can provide invaluable insight into appropriate treatment planning and the use of a biopsychosocial approach to symptom management.”26