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9 Articles in Volume 9, Issue #3
Amino Acids and Diet in Chronic Pain Management
Clinical Case Study of Low-level Laser Therapy
Comorbidity of Musculoskeletal Injury Pain and PTSD
Craniofacial Pain of Cardiac Origin
Intellectual and Moral Tasks in Intersection – Part 1
Opioid Antagonists in Pain Management
Post-traumatic Headaches, Migraines, and Sleep Disorders
Restoration of Normal Cervical Lordosis
Tension Headaches

Comorbidity of Musculoskeletal Injury Pain and PTSD

A biopsychosocial approach is best suited for assessment and treatment of traumatic musculoskeletal pain with concomitant post-traumatic stress disorder (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

Current Advances

As a consequence of the above studies, more clinical research of acute pain is now focusing not only on the management of the pain itself, but also on traumatic events that may have contributed to the onset of the acute pain episode (e.g., an automobile accident, work accident, assault, participation in war, etc.). Such traumatic events may have produced a concurrent diagnosis of post-traumatic stress disorder (PTSD) that, if not appropriately treated, may complicate physical recovery and reduction of pain. This is because PTSD has been shown to be associated with significant impairment in physical, psychological, social, and financial functioning.25 It should also be noted that many patients may have had past traumatic events not directly related to the current acute or chronic pain episode that may, nevertheless, make treatment success more difficult to achieve. As such, 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

Using the case of a motor vehicle accident (MVA) as an example, Koch and Samra25 noted that according to the American Psychiatric Association, “To meet symptomatic criteria for PTSD, one must have a combination of symptoms sampled from each of three theoretically distinct clusters: (a) re-experiencing symptoms (e.g., distressing nightmares of the MVA, distress following reminders of the MVA); (b) avoidant or numbing symptoms (e.g., behavioral or cognitive avoidance of reminders, emotional numbing, loss of recreational/social interests); and (c) hypoarousal symptoms (e.g., irritability, sleep disturbance). To meet full diagnostic criteria for PTSD…the individual must also meet certain duration requirements, and more importantly, symptoms must be associated with sincere distress or disability in his/her social or occupational role.”27

It should also be noted that the nature of traumatic life events is that they occur frequently (high exposure rate), but that the lifetime rate of the development of PTSD is low.27-30 Individuals are more likely to develop PTSD when the traumatic event is perceived as highly uncontrolled, unpredictable, and intentional.28,31,32 A study of the etiology of PTSD in injured adults revealed a higher likelihood of a history of assault, of thoughts that they were going to die at the time of the trauma, and of experiencing peritraumatic dissociation.6

Prevalence of PTSD reported by Breslau et al29 and Kessler et al30 indicate an estimated lifetime prevalence of 9% in the total sample (with 6% for men and 11% for women), and 8% in the total sample (with 5% for men and 10% for women, respectively). Research also shows that traumatic events themselves are not rare occurrences; 89.6% of the United States population is exposed to at least one traumatic event during the course of their lives.33 The overall estimated prevalence of PTSD is 5-6% for men and 10-12% for women.31 Violent and intentional events—such as rape, sexual assault, and physical assault—carry a lifetime prevalence of 32%, 31%, and 39%, respectively.31 Further, Resick31 noted that, in both men and women, rape was the most likely causative factor for the development of PTSD. With respect to chronic low back pain, PTSD has been shown to be seven times as likely to occur pre-injury rather than post-injury.34

Factors associated with PTSD not only include the type and severity of trauma sustained, but also include individuals’ previous exposure to prior traumatic events, the presence of premorbid mental health conditions, family history of psychiatric disorder, history of prior abuse, and life-threatening illness.6,31,33,35-37 In addition to the above risk factors, children may be at greater risk for developing PTSD due to destructive and avoidant coping behaviors modeled by parents, as well as parents’ inability to provide emotional support.31,38

Bowman28 discussed, as evidence of a genetic predisposition to the development (or not) of PTSD, the influence of neuroticism, a stable personality trait that contributes to experiencing life events through a “negative filter,” and the influence of resilience, which allows the individual greater adaptive response to life events. Other possible genetic-related factors that predispose individuals to greater exposure to traumatic events include impulsivity and sensation-seeking.28,31 Bowman28 also stated that persons with histories of previous mental disorder—particularly depression, substance abuse, conduct disorder, antisocial personality disorder, and borderline personality disorder—are also at increased risk for developing PTSD.

The Biopsychosocial Approach to Comorbid Musculoskeletal Pain and PTSD

As reviewed in numerous earlier publications,e.g.,26,39,40 the biopsychosocial model of pain is the most heuristic approach to understanding and treating the interactive biological, psychological and social factors often involved in pain syndromes. This model takes into account, not only the nociceptive or sensory processes of pain, but other important variables, such as affective, cognitive, and psychopathology. As such, it is especially suited for patients with comorbid physical (such as musculoskeletal pain) and mental (such as PTSD) disorders. Moreover, Turk and Gatchel41 discussed the importance of the difference between a disease and illness in the context of chronic pain. Disease is defined as a biologically-based event that is involved in the disruption of physiological functions and structures. An illness refers to how the patient and his or her social network respond to, live with, and perceive symptoms of pain and associated disabilities. The biopsychosocial model emphasizes factors correlated with both the disease and the illness of a patient. A distinction can also be made between nociception and pain.39 Nociception is the process in which a stimulus acts upon nerves that transfer information about possible tissue damage to the brain. From the transduction, transmission, and modulation of sensory information comes a subjective perception that results in a person’s experience of pain. Sensory information can go through an individual’s filter that can shape the experience of pain. Factors involved with an individual’s filter and associated with the shaping of the subjective experience of pain can include genetic composition, psychological status, prior learning history, and sociocultural influences.

Turk and Gatchel42 described the interactions between a person’s biological, psychological, and social factors with the statement: “Biological factors may initiate, maintain, and modulate physical perturbations, whereas psychological variables influence appraisals and perception of internal physiological signs and social factors shape patients’ behavioral responses to the perceptions of their physical perturbations.” In general, the physical, psychological, and social factors are constantly evolving and tend to shift throughout the progression of the disease or disability. For instance, during the onset and initial phases of a chronic condition, biological factors may be predominant in the experience of pain but, over time, social and psychological factors tend to take on the majority of influence over the symptoms and disability. The social and psychological factors can be detrimental in the maintenance and success of an intervention. For example, having an overwhelming fear of re-injury, or fearing a loss of autonomy or failure, can lead to reduced motivation of a patient to carry out an intervention or follow and comply with treatment. Treating physicians must be aware that treatment should go beyond that of altering physical factors such as the reduction of pain, but also include social and psychological factors that have been associated with pain. A biopsychosocial model can assist in treating patients in a more comprehensive manner and help determine the risks and benefits associated with treatment to chronic pain patients.

It is probable, at least in some percentage of cases, that patients who present with a current pain diagnosis (particularly in cases of a chronic or chronic-recurrent pain diagnosis) may also be presenting with a somatic preoccupation that can be linked to a history of childhood trauma.43 While these individuals may not necessarily meet DSM-IV-TR27 criteria for somatoform disorders, they often manifest their internal conflicts in the form of physical complaints, or have more severe psychological symptoms that manifest during a genuine physical illness.43 Sansone and colleagues pointed out, in their analysis of somatic preoccupation, that multiple variables do indeed have a significant inter-relationship with somatic preoccupation, including sexual abuse, depression, borderline personality disorder, and PTSD.43 While these findings cannot be applied to all cases, they do provide some insight into the complex picture of what factors are at play when treating individuals who have a comorbid presentation that includes any of the above psychosocial problems and a pain diagnosis.

Otis and colleagues44 further illuminated the relationship between PTSD and chronic pain. Their review focused on several models that may help explain how these two syndromes may interact with other, as well as techniques that might be useful for identifying and treating patients who present with both conditions. Among the factors the two conditions share in common are: fear avoidance behaviors, anxiety sensitivity, and catastrophizing, which might contribute to the maintenance of either condition. Several well-studied and validated measures were also suggested in this review for making a differential diagnosis with patients who might be experiencing the combined effects of PTSD and chronic pain. Indeed, a comprehensive initial evaluation prior to treatment can help to address the comorbidity of trauma and pain.

Premorbid Attributes

Certain psychological and biological attributes associated with PTSD are important when assessing acutely and chronically injured individuals. These attributes include pre-existing trauma-related appraisals of the self, others, and the world, as well as attentional biases toward stimuli pertaining to trauma.45 Memory difficulties associated with PTSD can also be present in other Axis I disorders, including major depressive disorder, as well as with traumatic brain injury, and they can also be mimicked in the case of malingering.45 Sbordone46 discussed how dissociative symptoms, amnesiac periods, and depersonalization can lead to the misdiagnosis of closed head injury following acute trauma. Decreases in hippocampal volume are also associated with declarative and autobiographical memory disturbances in PTSD.47 With reference to chronic pain, Martelli et al48 state that cognitive impairments, more than pain severity, are associated with mood changes, emotional distress, sleep disturbances, preoccupation with the body, and fatigue. Martelli et al48 further state cognitive impairments are also associated with individuals’ perceptions of the interference in daily activities of pain and contribute to a state of chronic stress.

Biopsychosocial Treatment of Pain

Given the complexities of acute and chronic pain, as well as possible effects of prior trauma events on treatment outcome, the biopsychosocial model for collaborative care is essential for optimizing treatment outcome. In his review of psychological risk factors associated with back and neck pain, Linton49 supports including this perspective in assessment and treatment. Schnyder and associates50 recommend assessment of life stressors, both past and present, as well as assessment of adaptational functioning in patients who are recovering from life-threatening injuries. Management of psychological issues during physical recovery following major injury is suggested by McFarlane.37 Matthews and Chinnery51 also emphasize that medical and allied health professionals who provide services to accident survivors must have an understanding of PTSD to provide appropriate referrals. Individuals whose injuries are less serious can also suffer consequences related to distress, and suggest incorporating procedures for identifying those at high risk for poor outcome.52 While elevations in distress following accidents is high, following the patient’s recovery course and allowing time for the patient’s stress to subside can aide in overall treatment.53 Mayou and Farmer54 recommend a supportive approach, sympathetic reassurance, and encouragement while remaining watchful for signs that patients may require extra care, rather than immediate debriefing.

While management of chronic pain remains a significant concern, factors associated with acute pain—more specifically acute low back pain subsequent to a major injury—are as challenging for health care providers given the perceptual complexities, the psychological and socioeconomic aspects associated with the pain experience, as well as potential effects of pre-injury traumatic life events discussed previously.39,55 Early return-to-work, while desirable in terms of costs to employers and employees alike, may not be in the patient’s best interest, even in the case of less severe injuries such as soft tissue injury.56 An increase in the stress levels of an individual affected by pre-injury PTSD may serve to magnify the relationship between the acute symptoms and the maladaptive coping mechanisms associated with PTSD.57

Cognitive-Behavioral Therapy (CBT)

A biopsychosocial treatment protocol which includes a strong CBT component to address PTSD symptomatology has been found to be important. Considerable research supports the efficacy of CBT in ameliorating trauma-related distress, involving treatment protocols of anywhere from 4 to 16 sessions, and including such therapeutic elements as psychoeducation, stress management, cognitive restructuring, and prolonged imaginal exposure.58-60 The majority of this research, however, has focused on general trauma (e.g., rape, accidents, etc.) without an emphasis on orthopaedic injury and the concurrent difficulties of physical/medical disability that can complicate recovery. Several studies13,14,61 have demonstrated the efficacy of CBT, in comparison to other interventions, in reducing emotional distress among accident victims. However, only one of these studies62 used an early intervention strategy (5-10 weeks post-injury) and none of the studies examined the impact of emotional distress on physical functioning and recovery subsequent to injury. Thus, there is currently a lack of methodologically-sound studies evaluating the effect of CBT on both the functional and emotional outcome after orthopaedic extremity trauma, especially with a military population! However, this will soon be remedied by a Department of Defense-funded clinical research study now being conducted by Gatchel and colleagues. It is important to note, however, that the clinical effectiveness of CBT is only guaranteed when it is integrated as part of a more comprehensive, interdisciplinary rehabilitation program. Such a program must have a biopsychosocial perspective that incorporates treatment of biological, psychosocial, and behavioral factors that have been shown to be interdependent—especially in chronic pain.

Comorbid Acute Low Back Pain and PTSD

The authors recently reviewed a large clinical sample of acute low back pain (ALBP) patients to preliminarily evaluate data related to pre-injury traumatic life events and stressors. Selection for inclusion in this review was based on database-search parameters that revealed 32 of more than 900 study participants whose diagnosis included PTSD (lifetime, current, or both) at baseline assessment. Additional psychiatric diagnostic categories present in this PTSD selection sample were also noted, and their frequencies are outlined in Tables 1 and 2. As can be seen, the DSM Axis I clinical disorder diagnoses found to be most often comorbid with the diagnosis of PTSD included major depressive disorder, substance abuse, and pain disorder. The most frequently comorbid DSM Axis II personality disorder diagnoses included obsessive-compulsive personality disorder, paranoid personality disorder, and borderline personality disorder.

Table 1. Comorbid Axis I Diagnoses
Description Frequency
Major Depressive Disorder 17
Bipolar Disorder 2
General Anxiety Disorder 1
Dysthymia 3
Depression, Other 1
Substance Abuse/Dependence 20
Specific Phobia 4
Social Phobia 3
Agoraphobia/Panic Disorder 6
Obsessive Compulsive Disorder 1
Anorexia Nervosa 1
Bulimia/Binge Eating 4
Somatization Disorder 3
Pain Disorder 13
Adjustment Disorder 5
Note. Information derived from data collection for the Acute Low Back Pain Study at The University of Texas Southwestern Medical Center, Dallas, Texas, Robert J. Gatchel, Ph.D., Principal Investigator.

Table 2. Comorbid Axis II Diagnoses
Description Frequency
Obsessive Compulsive Personality Disorder 8
Paranoid Personality Disorder 7
Antisocial Personality Disorder 3
Narcissistic Personality Disorder 4
Borderline Personality Disorder 6
Histrionic Personality Disorder 2
Avoidant Personality Disorder 1
Note. Information derived from data collection for the Acute Low Back Pain Study at The University of Texas Southwestern Medical Center, Dallas, Texas, Robert J. Gatchel, Ph.D., Principal Investigator.

Further review of these data centered on the PTSD diagnostic section. Findings reported in Tables 3-5 include: the type(s) of traumatic events experienced, the age of the individual at the time of the first traumatic event, and the total number of traumatic events experienced. As revealed in these Tables, sexual abuse and physical assault occurred most often in this sample. The first trauma occurrence, whether in childhood or adulthood, was recorded in Table 4.

Table 3. Traumatic Life Events
Description Frequency
Sexual Abuse 10
Emotional Abuse 2
Physical Abuse 6
Death of a Child 3
Physical Assault 7
Motor Vehicle Accident 3
Death of Spouse 2
Death of Family Member 5
Death of Friend/Coworker 3
Witnessed Death 6
Missing Data 9
Note. Individuals may have reported multiple traumatic life events; therefore, n>32. Information derived from data collection for the Acute Low Back Pain Study at The University of Texas Southwestern Medical Center, Dallas, Texas, Robert J. Gatchel, Ph.D., Principal Investigator.

Table 4. Age at time of Trauma Occurrence*
Description Frequency
Childhood 12
Adolescence 3
Adulthood 13
Missing Data 4
Note. *Age category represents first traumatic life event. Information derived from data collection for the Acute Low Back Pain Study at The University of Texas Southwestern Medical Center, Dallas, Texas, Robert J. Gatchel, Ph.D., Principal Investigator.

Table 5. Number of Traumatic Injuries across Lifespan
Description Frequency
One (1) 8
Two (2) 9
Three (3) or more 11
Missing Data 4
Note. Information derived from data collection for the Acute Low Back Pain Study at The University of Texas Southwestern Medical Center, Dallas, Texas, Robert J. Gatchel, Ph.D., Principal Investigator.

Case Summaries

The following case summaries are representative of the ALBP study participants who were found to be affected by PTSD. These case summaries provide examples of what an acutely-injured individual may be experiencing when pre-injury trauma has occurred in his or her lifetime. Two of the cases highlight childhood trauma, one of which was chronic sexual abuse of a child. The other cases highlight crime victimization. Two cases include witnessing the violent death of a spouse or family member. Three individuals were invited into treatment and completed the study protocol, while a fourth individual was not included due to severe mental illness. Of interest is the dysthymic state of the individual who had suffered chronic childhood sexual abuse and her significant past medical and surgical history. Also interesting is that, in each case, memory disturbances and avoidance are present.

“...case summaries are representative of the ALBP study participants who were found to be affected by PTSD. These case summaries provide examples of what an acutely-injured individual may be experiencing when pre-injury trauma has occurred in his or her lifetime.”

Case 1

Diagnoses. Major depressive disorder, lifetime; alcohol abuse, lifetime; PTSD, lifetime; and pain disorder, current. Screening information revealed a 28-year-old single African American male who entered the study three weeks following a twisting low back injury that occurred when he exited his work vehicle. He described sharp pain in the lower left back with shooting pain down the right leg into the right calf. Lumbar strain was diagnosed by a physician, and he was treated with anti-inflammatory medication and ten physical therapy sessions prior to entry into the study. His prior medical history was positive for knee injury with cartilage tears and “cracked bones.” Ten years prior to the study entry, he was the victim of robbery (when he was 18 years old) in which he was beaten about the head with brass knuckles. He fell to the sidewalk and hit his head, which resulted in a cervical strain. His “baby brother” was killed in the attack. Subsequent to this event, the patient experienced depressed mood, markedly diminished interest or pleasure, significantly decreased appetite, sleep disturbance, psychomotor retardation, and feelings of worthlessness with some thoughts of his own death. He drank heavily following this traumatic event for approximately one year. At the time of the trauma, he recalled feeling terrified when the robbery occurred because his brother did not die right away. Positive responses for past occurrences that meet PTSD diagnostic criteria included: recurrent and intrusive distressing recollections; recurrent or distressing dreams; avoidance; diminished interest or participation in significant activities; sense of foreshortened future; sleep disturbance; irritability or outburst of anger; and hypervigilance. A positive response was noted for past and current intense psychosocial distress on exposure to internal or external cues.

Case 2

Diagnoses. Bipolar disorder, current/ lifetime; PTSD, lifetime; borderline personality disorder, current/lifetime; narcissistic personality disorder, current/ lifetime; and obsessive/compulsive personality disorder, current/lifetime. Screening information revealed a 35-year-old single Caucasian male who was screened and evaluated three weeks following the onset of low back pain of unknown etiology. The patient stated that he was “not sure how it happened. . . maybe from moving furniture around.” He had no prior low back symptoms or injury, and reported general medical conditions including diabetes and asthma. One year prior to the low back injury (at age 34), he was the victim of an assault in which he was stabbed 18 times. His response involved intense fear. Positive responses meeting PTSD diagnostic criteria for lifetime occurrence included: recurrent and intrusive distressing recollections of the event; recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring; intense psychological distress at exposure to internal or external cues; physiological reactivity on exposure to internal or external cues; avoidance; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; restricted range of affect; a sense of foreshortened future; sleep disturbance; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response.

Case 3

Diagnoses. Dysthymia, lifetime; PTSD, lifetime. Screening information revealed a 50-year-old married Caucasian female who was screened four weeks after falling on the steps outside of her office, and landing on her left buttock and back. The injury was reported the following morning and she was evaluated by a physician who referred her for an orthopedic evaluation, as well as CT and MRI scans. Her past medical history was positive for a broken ankle, and hospitalizations for childbirth, broken ankle, appendectomy, sinus surgery, gallbladder surgery, hysterectomy, catatonic state, and suicide attempt. This patient had experienced multiple and chronic trauma throughout her life: she was sexually abused beginning at age 4 for an unknown length of time; was the victim of domestic violence over 11 years of marriage beginning at age 19; and suffered the loss of her grandmothers at age 7. She experienced threats by the perpetrators of the sexual abuse (four different individuals), and she was punished for telling and was not believed. The sexual abuse was identified as the trauma that affected her the most. Her reactions to the sexual trauma included: feelings of helplessness; recurrent and intrusive distressing recollections of the event; recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring; and intense psychological distress on exposure to internal or external cues. Following the trauma, she experienced feelings of detachment or estrangement from others, restricted range of affect, a sense of a foreshortened future, sleep disturbance, irritability or outbursts of anger, and difficulty concentrating.

Case 4

Diagnoses. Major depression, current; specific phobia, current/lifetime; PTSD, lifetime, in partial remission; and pain disorder, current. Also noted were paranoid traits and schizoid features. Screening information revealed a 42-year-old widowed African-American female who was screened six months following the onset of low back pain after she had bent over to pick up trash off her kitchen floor at home. She denied previous low back problems and any general medical conditions. However, she later related at the baseline evaluation that she is sick “quite a bit” with colds, headaches, body aches and pains. When in the eighth grade (approximately age 13-14), her brother was murdered, after which she obtained four weekly counseling sessions at school. At age 21, her infant son died of SIDS. She stated that she held him after he had died. At age 23, her husband was murdered by his brother on Easter Sunday. Traumatic events have either been witnessed or she has been confronted by events that involved actual or threatened death or serious injury. Her responses involved intense fear, helplessness, or horror. She experienced recurrent and intrusive distressing recollections of the event, recurrent distressing dreams of the event, and acted or felt as if the traumatic event were recurring. She also had intense psychological distress on exposure to internal or external cues (avoided holding babies), and experienced physiological reactivity on exposure to internal or external cues. Since the trauma, she has displayed the following: employed avoidance of thoughts and activities; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; and a sense of a foreshortened future. Also, she has had difficulty concentrating. Lesser issues were noted with difficulties falling or staying asleep and irritability or outbursts of anger. She is still mildly affected by these events and related, though, that she still experiences difficulties around her son’s birthday, during holidays, and particularly when she is lonely.

“As reviewed, there is a plethora of empirical studies demonstrating how psychosocial trauma can affect recovery of physical functioning after an accident.”


Comorbid traumatic musculoskeletal injuries and PTSD are not an uncommon syndrome that is seen by pain-care specialists. As reviewed, there is a plethora of empirical studies demonstrating how psychosocial trauma can affect recovery of physical functioning after an accident. It is, therefore, of great importance that health-care providers simultaneously evaluate both the physical and psychosocial concomitants of accidents causing traumatic musculoskeletal pain.

The biopsychosocial approach to such assessment and treatment is best suited for this task because it takes into account the unique interaction between an individual’s biological, psychological and social factors, and then appropriately “tailors” the treatment for each individual. This is now seen as the best approach for both civilian and military trauma victims.

Last updated on: July 8, 2018
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