Disability and depression after orthopaedic trauma
Introduction
Musculoskeletal injury is a common cause of impairment (pathophysiology), but the correlation of impairment with pain intensity and magnitude of disability is limited [1]. Psychosocial factors explain a large proportion of the variance in disability for various orthopaedic pathologies [2]. For instance, catastrophic thinking (the tendency to magnify pain, feel helpless when faced with pain, and ruminate on the pain experience), pain anxiety (cognitive and physiological anxiety when experiencing pain, as well as avoidance of activities that cause pain), and symptoms of depression tend to account for more of the variation in magnitude of disability and pain intensity than measure of musculoskeletal pathology and impairment for many conditions [3].
Given the moderate to strong correlation between psychological factors and musculoskeletal disability [4], [5], it is surprising that they are not routinely addressed in the care of patients recovering from orthopaedic trauma. To date, we know that depressive symptoms are common after trauma, and they correlate with disability [6]; Post Traumatic Stress Disorder (PTSD) is common after orthopaedic trauma [7], [8]; and patients who develop PTSD after trauma have more depressive symptoms within days of the injury [9]. A previous study in the United States found that symptoms of depression 1–2 months after 1 or more fractures correlate with magnitude of disability 5–8 months after injury [23]. Since psychosocial factors are culturally mediated [10] we were curious if the conclusions drawn from that study would also apply in a cohort of orthopaedic trauma patients in The Netherlands. If prospective studies consistently demonstrate longitudinal relationships between psychological factors measured early on in recovery and greater pain intensity and magnitude of disability during the late stage of recovery, the next step would be an intervention to try to ameliorate this.
The aim of this study is to prospectively assess the relationship between psychological factors (depression and PTSD), coping strategies (pain catastrophizing and pain anxiety), pain intensity (measured on an ordinal scale), and magnitude of disability in a sample of orthopaedic trauma patients in The Netherlands. Our primary null-hypothesis is that symptoms of depression, PTSD, and catastrophic thinking measured 1–2 months after musculoskeletal trauma do not correlate with disability 5–8 months after injury. In addition we addressed the prevalence of an estimated diagnosis of major depression and PTSD, at enrollment and final evaluation, and changes in magnitude of disability, symptoms of depression, and symptoms of PTSD between enrollment and final evaluation.
Section snippets
Patients
Adult patients visiting the outpatient office of the orthopaedic trauma service within 1 or 2 months after 1 or more fractures, tendon or ligament injuries were invited to participate in this prospective IRB-approved study. The timeframe of 1–2 months was used in prior studies and based on our experience that recovery is well established (e.g. taking little or no pain medication, bearing weight, making progress with exercises) in most patients by this time. The patients were enrolled by an
Results
There were moderate correlations between symptoms of depression (CES-D) and symptoms of PTSD (SVL) at enrollment and magnitude of disability 5–8 months after trauma. Catastrophic thinking (PCS) at enrollment and magnitude of disability 5–8 months after trauma showed a small correlation (Table 2). Sex and the Injury Severity Score (ISS) correlated with disability at enrollment, but not at the final evaluation. Patients treated operatively had greater disability at enrollment and at final
Discussion and conclusions
In The Netherlands, symptoms of depression measured 1–2 months after musculoskeletal trauma correlate with disability 5–8 months after this trauma, just as they do in the United States [23]. Disability at 5–8 months also correlated with symptoms of PTSD and catastrophic thinking. Although excluding the variables depression, symptoms of PTSD and catastrophic thinking from the final multiple linear model would result in a large decrease in the total predicting value of the model (adjusted R
Conflict of interest statement
Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Ethical approval
The work has been approved by the appropriate ethical committees related to the institution(s) in which it was performed and subjects gave informed consent to the work. A copy of the letter from our ethical committee approving this study is available.
Acknowledgments
We would like to thank the Harvard Catalyst for their statistical support.
References (29)
- et al.
Value of psychological evaluation of the hand surgical patient
J Hand Surg Am
(2008) - et al.
The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large 265 urban hospital
J Oral Maxillofac Surg
(2003) - et al.
The influence of culture: holistic versus analytic perception
Trends Cogn Sci
(2005) - et al.
Pain catastrophizing and general health status in a large Dutch community sample
Pain
(2002) - et al.
Prevalence and correlates of DSM-IV major depression in an Australian national survey
J Affect Disord
(2003) - et al.
Assessment of severity in low-back disorders
Spine (Phila Pa 1976)
(1984) - et al.
Idiopathic arm pain
J Bone Joint Surg Am
(2004) - et al.
Psychological factors associated with idiopathic arm pain
J Bone Joint Surg Am
(2005) - et al.
A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain
Spine (Phila Pa 1976)
(2002) - et al.
Depression in orthopaedic trauma patients. Prevalence and severity
J Bone Joint Surg Am
(2006)