Psychosocial support in rehabilitation after orthopedic injuries

Association Between Preoperative Multidimensional Psychological Distress and Physical Function After Surgery for Sports-Related Injury

Background

Psychological distress after orthopaedic surgery can lead to worse outcomes, including higher levels of disability and pain and lower quality of life. The 10-item Optimal Screening for Prediction for Referral and Outcome-Yellow Flag (OSPRO-YF) survey screens for multiple psychological constructs relevant to recovery from orthopaedic injury and may be useful to preoperatively identify patients who may require further psychological assessment and possible intervention after surgery.

Purpose/Hypothesis

To determine the association between the OSPRO-YF and physiological patient-reported outcomes (PROs). It was hypothesized that higher OSPRO-YF scores (indicating worse psychological distress) would be associated with worse PRO scores at time of return to sport.

Study Design

Case series; Level of evidence, 4.

Methods

This study evaluated 107 patients at a single, academic health center who were assessed at a sports orthopaedics clinic and ultimately treated surgically for injuries to the knee, shoulder, foot, or ankle. Preoperatively, patients completed the OSPRO-YF survey as well as the following PRO measures: Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numeric Evaluation, numeric rating scale for pain; American Shoulder and Elbow Surgeons standardized shoulder assessment form for patients with shoulder injuries, the International Knee Documentation Committee score (for patients with knee injuries), and the Foot and Ankle Ability Measure (FAAM; for patients with foot or ankle injuries). At the time of anticipated full recovery and/or return to sport, patients again completed the same PRO surveys. Multivariable regression was used to evaluate the association between total OSPRO-YF score at baseline and PRO scores at the time of functional recovery.

Results

The baseline OSPRO-YF score predicted postoperative PROMIS Physical Function and FAAM Sports scores only. A 1-unit increase in the OSPRO-YF was associated with a 0.55-point reduction in PROMIS Physical Function (95% CI, -1.05 to -0.04; P = .033) indicating worse outcomes. Among patients who underwent ankle surgery, a 1-unit increase in OSPRO-YF was associated with a 6.45-point reduction in FAAM Sports (95% CI, -12.0 to -0.87; P = .023).

Conclusion

The study findings demonstrated that the OSPRO-YF survey predicts certain long-term PRO scores at the time of expected return to sport, independent of baseline scores.

Interventional Efforts to Reduce Psychological Distress After Orthopedic Trauma: A Systematic Review

BACKGROUND

Unanticipated severe injury to part of the musculoskeletal system, referred to as orthopedic trauma, can be debilitating. It can also be accompanied by equally debilitating psychological distress, but little is known about the effective interventions for psychological sequelae of orthopedic trauma.

QUESTIONS/PURPOSES

We sought to determine the effectiveness of interventions on psychological outcomes, such as post-traumatic stress disorder (PTSD), depression, and pain catastrophizing (feelings of helplessness, excessive rumination, and exaggerated description of pain), after major orthopedic trauma.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement as guidelines, we systematically searched Scopus, PubMed, and Google Scholar. Studies included for review were English-language interventional studies in an orthopedic trauma population that included assessment of post-injury psychological distress or disability as either a primary or secondary aim.

RESULTS

Twelve studies were identified, including six randomized trials, three prospective cohort studies, and three retrospective cohort studies. Study sample sizes ranged from 48 to 569 patients, the mean age ranged from 29 to 52.8 years, and the percentage of male patients ranged from 38 to 90%. We examined four categories of interventions. Peer group treatment (one study) significantly reduced rates of depression but had low participation rates. Brief interventions to teach coping and self-efficacy skills (two studies) decreased depression, pain catastrophizing, and anxiety scores while increasing self-efficacy on short-term follow-up. Individualized counseling and rehabilitation (four studies) resulted in a consistent reduction in the risk of PTSD. Early amputation was found to result in lower rates of PSTD than limb salvage in US military personnel (four studies). One study examined surgeons' confidence in dealing with possible psychological distress; surgeons who participated in a program on collaborative care were significantly more confident that they could help their patients with such issues.

CONCLUSION

Interventional strategies, including group interventions, brief individual interventions, longitudinal counseling, and consideration of early amputation in selected populations have proved effective in reducing negative psychological sequelae of major orthopedic trauma. Further research that determines the effects of interventions in this population is needed.

Software-Based Postoperative Communication With Patients Undergoing Spine Surgery

STUDY DESIGN

Observational study.

OBJECTIVES

Perioperative patient anxiety is a major concern in orthopedic surgery. Mobile messaging applications have been used in a number of healthcare settings. The goal of this project is to develop a novel mobile messaging application aimed at decreasing perioperative patient anxiety in spine surgery patients.

METHODS

Postoperative recovery journals were collected from patients undergoing spine surgery. Journals were used as a framework to develop a software-messaging library. A subsequent cohort of patients received daily text messages with educational material regarding their recovery for 14 days after discharge from their operative admission. Patients ranked the usefulness of the survey on day 14; further feedback was obtained via interviews.

RESULTS

Nineteen postoperative recovery journals were collected and analyzed. Content regarding postoperative recovery was compiled. The pilot group consisted of 21 patients. Average rating of the application on a 1 to 5 scale with 5 being "very useful" was 4.57. Of the 12 patients available for postoperative interviews, 11 felt the content of the messages was relevant. Nine of 12 patients felt the application made it less likely for them to call clinic.

CONCLUSIONS

The study presents a unique mobile phone messaging tool to offer patients support in the 2 weeks following spine surgery. The tool was felt to be useful by nearly all patients, had a high degree of patient engagement, and made the majority of patients less likely to call clinic.

The effectiveness of multi-dimensional resilience rehabilitation programs after traumatic physical injuries: a systematic review and meta-analysis

Objective: To synthesize evidence of the effectiveness of socio-ecological resilience rehabilitation programs on returning to work (RTW), self-efficacy, and stress mitigation following traumatic physical injuries.Methods: PubMed, Scopus, Proquest, Cinahl, Web of Science, Clinical Trials Database, and the Cochrane Central Register of Controlled Trials databases were searched. Methodological quality was assessed using the PEDro tool.Study selection: Randomized interventions aimed at promoting resilience.Data extraction: Twenty one studies were reviewed (11,904 participants). Data from 19 studies of high methodological quality were pooled using a random-effects meta-analysis. Mean differences for continuous outcomes and risk ratios for binary outcomes were calculated.Data synthesis: Resilience rehabilitation programs significantly increased the likelihood of ever RTW (OR 2.09, 95% CI 0.99-4.44, p = 0.05), decreased the number of days taken to return to work (mean difference -7.80, 95% CI -13.16 to -2.45, p ≤ 0.001), and increased total self-efficacy scores (mean difference 5.19, 95% CI 3.12-7.26, p < 0.001). Subgroup analyses found that favorable return to work outcomes resulted from programs involving workplace support (p < 0.001) and for people with musculoskeletal or orthopedic injuries (p = 0.02).Conclusions: Compared to rehabilitation programs providing standard care following injuries, programs aimed at developing resilience could improve reemployment outcomes and self-efficacy.Implications for rehabilitationIndividual resilience may be an important factor promoting functional recovery after traumatic injury.Resilience rehabilitation programs are effective in enabling patients' return to work and increasing their self efficacy. In particular, programs involving the workplace are important components for enabling optimal work participation outcomes.

An integrated-delivery-of-care approach to improve patient reported physical function and mental wellbeing after orthopedic trauma: study protocol for a randomized controlled trial

BACKGROUND

Orthopedic trauma injury impacts nearly 2.8 million people each year. Despite surgical improvements and excellent survivorship rates, many patients experience poor quality of life (QOL) outcomes years later. Psychological distress commonly occurs after injury. Distressed patients more frequently experience rehospitalizations, pain medication dependence, and low QOL. This study was developed to test whether an integrative care approach (IntCare; ten-step program of emotional support, education, customized resources, and medical care) was superior to usual care (UsCare). The primary aim was to assess patient functional QOL (objective and patient-reported outcomes) with secondary objectives encompassing emotional wellbeing and hospital outcomes. The primary outcome was the Lower Extremity Gain Scale score.

METHODS/DESIGN

A single-blinded, single-center, repeated measures, randomized controlled study is being conducted with 112 orthopedic trauma patients aged 18-85 years. Patients randomized to the IntCare group have completed or are receiving a guided ten-step support program during acute care and at follow-up outpatient visits. The UsCare group is being provided the standard of care. Patient-reported outcomes and objective functional measures are collected at the hospital and at weeks 2, 6, and 12 and months 6 and 12 post surgery. The main study outcomes are changes in Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires of Physical Function quality of life, Satisfaction with Social Roles, and Positive-Illness Impact, Post-Traumatic Stress Disorder Check List, and the Tampa Scale of Kinesiophobia-11 from baseline to month 12. Secondary outcomes are changes in objective functional measures of the Lower Extremity Gain Scale, handgrip strength, and range of motion of major joints from week 2 to month 12 post surgery. Clinical outcomes include hospital length of stay, medical complications, rehospitalizations, psychological measures, and use of pain medications. A mixed model repeated measures approach assesses the main effects of treatment and time on outcomes, as well as their interaction (treatment × time).

DISCUSSION

The results from this study will help determine whether an integrative care approach during recovery from traumatic orthopedic injury can improve the patient perceptions of physical function and emotional wellbeing compared to usual trauma care. Additionally, this study will assess the ability to reduce the incidence or severity of psychological distress and mitigate medical complications, readmissions, and reduction of QOL after injury.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02591472 . Registered on 28 October 2015.

Return-to-work coordination programmes for improving return to work in workers on sick leave

BACKGROUND

To limit long-term sick leave and associated consequences, insurers, healthcare providers and employers provide programmes to facilitate disabled people's return to work. These programmes include a variety of coordinated and individualised interventions. Despite the increasing popularity of such programmes, their benefits remain uncertain. We conducted a systematic review to determine the long-term effectiveness of return-to-work coordination programmes compared to usual practice in workers at risk for long-term disability.

OBJECTIVES

To assess the effects of return-to-work coordination programmes versus usual practice for workers on sick leave or disability.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE, Embase, CINAHL and PsycINFO up to 1 November 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled workers absent from work for at least four weeks and randomly assigned them to return-to-work coordination programmes or usual practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text articles for study eligibility; extracted data; and assessed risk of bias from eligible trials. We contacted authors for additional data where required. We conducted random-effects meta-analyses and used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

We identified 14 studies from nine countries that enrolled 12,568 workers. Eleven studies focused on musculoskeletal problems, two on mental health and one on both. Most studies (11 of 14) followed workers 12 months or longer. Risk of bias was low in 10 and high in 4 studies, but findings were not sensitive to their exclusion.We found no benefits for return-to-work coordination programmes on return-to-work outcomes.For short-term follow-up of six months, we found no effect on time to return to work (hazard ratio (HR) 1.32, 95% confidence interval (CI) 0.93 to 1.88, low-quality evidence), cumulative sickness absence (mean difference (MD) -16.18 work days per year, 95% CI -32.42 to 0.06, moderate-quality evidence), the proportion of participants at work at end of the follow-up (risk ratio (RR) 1.06, 95% CI 0.86 to 1.30, low-quality evidence) or on the proportion of participants who had ever returned to work, that is, regardless of whether they had remained at work until last follow-up (RR 0.87, 95% CI 0.63 to 1.19, very low-quality evidence).For long-term follow-up of 12 months, we found no effect on time to return to work (HR 1.25, 95% CI 0.95 to 1.66, low-quality evidence), cumulative sickness absence (MD -14.84 work days per year, 95% CI -38.56 to 8.88, low-quality evidence), the proportion of participants at work at end of the follow-up (RR 1.06, 95% CI 0.99 to 1.15, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 1.03, 95% CI 0.97 to 1.09, moderate-quality evidence).For very long-term follow-up of longer than 12 months, we found no effect on time to return to work (HR 0.93, 95% CI 0.74 to 1.17, low-quality evidence), cumulative sickness absence (MD 7.00 work days per year, 95% CI -15.17 to 29.17, moderate-quality evidence), the proportion of participants at work at end of the follow-up (RR 0.94, 95% CI 0.82 to 1.07, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 0.95, 95% CI 0.88 to 1.02, low-quality evidence).We found only small benefits for return-to-work coordination programmes on patient-reported outcomes. All differences were below the minimal clinically important difference (MID).

AUTHORS' CONCLUSIONS

Offering return-to-work coordination programmes for workers on sick leave for at least four weeks results in no benefits when compared to usual practice. We found no significant differences for the outcomes time to return to work, cumulative sickness absence, the proportion of participants at work at end of the follow-up or the proportion of participants who had ever returned to work at short-term, long-term or very long-term follow-up. For patient-reported outcomes, we found only marginal effects below the MID. The quality of the evidence ranged from very low to moderate across all outcomes.

Prevalence of Depression and Posttraumatic Stress Disorder After Acute Orthopaedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aims to systematically assess the existing literature and to derive a pooled estimate of the prevalence of depression and posttraumatic stress disorder (PTSD) in adult patients after acute orthopaedic trauma.

DATA SOURCES

A comprehensive search of databases, including MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials databases was conducted through June 2015.

STUDY SELECTION

We included studies that assessed the prevalence of depression or PTSD in patients who experienced acute orthopaedic trauma to the appendicular skeleton or pelvis. Studies with a sample size of ≤10 were excluded.

DATA EXTRACTION

Two authors independently extracted data from the selected studies and the data collected were compared with verify agreement.

DATA SYNTHESIS

Twenty-seven studies and 7109 subjects were included in the analysis. Using a random-effects model, the weighted pooled prevalence of depression was 32.6% (95% CI, 25.0%-41.2%) and the weighted pooled prevalence of PTSD was 26.6% (95% CI, 19.0%-35.9%). Six studies evaluated the prevalence of both depression and PTSD in patients with acute orthopaedic injuries. The weighted pooled prevalence of both depression and PTSD for those patients was 16.8% (95% CI, 9.0%-29.4%).

CONCLUSIONS

Nearly one-third of patients suffer from depression and more than one-quarter of patients suffer from PTSD after an acute orthopaedic injury suggesting that strategies to address both the mental and physical rehabilitation after an orthopaedic injury should be considered to optimize patient recovery.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Identifying the prevalence, trajectory, and determinants of psychological distress in extremity sarcoma

Objective. Extremity sarcoma (ES) is a rare cancer that presents with unique challenges. This study was performed to identify the prevalence, trajectory, and determinants of distress and characterise sources of stress in this cohort. Methods. Consecutive patients with ES were prospectively recruited between May 2011 and December 2012. Questionnaires were administered during initial diagnosis and then six months and one year after surgery. Results. Distress was reported by about a third of our cohort and associated with poorer physical function, poorer quality of life, and pain. In addition to fears regarding mortality and life role changes, the most common sources of stress were centered on dissatisfaction with the healthcare system, such as frustrations with a lack of communication with the hospital regarding appointments and lack of education regarding management and outcomes. Conclusions. Psychological distress presents early in the cancer journey and persists up to one year after surgery. Distress is associated with negative outcomes. Active screening and effective interventions are necessary to improve outcomes. Sources of stress have been identified that may be amenable to targeted interventions.

Effectiveness of an educational intervention on levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma

AIM

This paper is a report of a study of the effectiveness of a pain management educational intervention on level of pain, anxiety and self-efficacy among patients with musculoskeletal trauma and consequent orthopaedic surgery.

BACKGROUND

Substantial evidence supports the use of preoperative education to improve patient outcomes. Educational interventions are common in preparing patients for orthopaedic surgery.

METHODS

A pre- and post-test design (quasi-experimental) was employed in 2006 with patients assigned either to a control (usual care) or an experimental group (usual care plus educational intervention). The 30-minute educational intervention consisted of information about pain, coping strategies and breathing relaxation exercises. The outcome measures were scores for pain, anxiety, self-efficacy, analgesic use and length of hospital stay and these were measured before surgery and on day 2, day 4, day 7, 1 month and 3 months after surgery.

RESULTS

A total of 125 patients completed the study (control, n = 63; experimental = 62). The experimental group reported statistically significantly lower levels of pain, less anxiety and better self-efficacy during hospitalization (before surgery to day 7), as compared to the control group. The experimental group had more requests for analgesics at day 2 only. There were no statistically significant effects on length of stay. At the 3-month evaluation, a statistically significant effect on anxiety level was found in favour of the experimental group.

CONCLUSION

Patients may benefit from this educational intervention in terms of relieving pain, anxiety and improving self-efficacy, and the educational intervention could be incorporated as part of routine care to prepare musculoskeletal trauma patients for surgery.

Outcome after Minor Traffic Accidents: A Follow-up Study of Orthopedic Patients in an Inner-City Area Emergency Room

This follow-up study of consecutive traffic accident victims aimed to characterize the variation in recuperation time, to estimate the incidence of delayed recovery, and to identify predictors of nonrecovery 1 and 6 months after the accident. This study included 318 of 811 consecutive patients. Whiplash type neck injuries (48%) were the most common, followed by other minor injuries (38%). Self-perceived recovery was reported by 31% and 56% of the patients at 1 and 6 months, respectively. With control for mutual confounding variables in a multivariate model, injury severity, working status, and education were associated, respectively, with 4.5-fold, 3.2-fold and 2.3-fold gradients in odds of recovery not reported at 1 month. At 6 months, only working status (odds ratio [OR], 3.2) and education (OR, 2.3) were associated with the risk of reporting nonrecovery. The authors concluded that social factors are important predictors of outcome 1 and 6 months after minor traffic accidents.

Early Predictors of Long-Term Disability After Injury

• Background Improving outcomes after serious injury is important to patients, patients’ families, and healthcare providers. Identifying early risk factors for long-term disability after injury will help critical care providers recognize patients at risk.

• Objectives To identify early predictors of long-term disability after injury and to ascertain if age, level of disability before injury, posttraumatic psychological distress, and social network factors during hospitalization and recovery significantly contribute to long-term disability after injury.

• Methods A prospective, correlational design was used. Injury-specific information on 63 patients with serious, non–central nervous system injury was obtained from medical records; all other data were obtained from interviews (3 per patient) during a 2½-year period. A model was developed to test the theoretical propositions of the disabling process. Predictors of long-term disability were evaluated using path analysis in the context of structural equation modeling.

• Results Injuries were predominately due to motor vehicle crashes (37%) or violent assaults (21%). Mean Injury Severity Score was 13.46, and mean length of stay was 12 days. With structural equation modeling, 36% of the variance in long-term disability was explained by predictors present at the time of injury (age, disability before injury), during hospitalization (psychological distress), or soon after discharge (psychological distress, short-term disability after injury).

• Conclusions Disability after injury is due partly to an interplay between physical and psychological factors that can be identified soon after injury. By identifying these early predictors, patients at risk for suboptimal outcomes can be detected.

Impact of in-home defibrillators on postmyocardial infarction patients and their significant others: an interview study

OBJECTIVE

To investigate the impact of automated external defibrillator (AED) placement in the homes of postmyocardial infarction (MI) patients and their significant others.

DESIGN

This qualitative study used a semistructured interview to examine a nonrandomized convenience sample recruited from a larger study of home AEDs.

SETTING AND PARTICIPANTS

Patients (and their significant others) were recruited from an ongoing study of AED use in the home. Seventeen interviews with 15 patients (14 men, 1 woman) and 16 significant others (1 man, 15 women) aged 39 to 80 years were performed in patients' homes.

METHODS

Verbatim transcripts of audiotaped interviews were reviewed, and responses were categorized. Other data were obtained from hospital chart abstraction.

RESULTS

The majority of subjects noted only positive effects of the presence of home AEDs (eg, giving them feelings of security and control). There was no evidence that AED presence in the home caused excessive anxiety or stress either in patients or their significant others, nor were they perceived to cause relationship stress. On average, patients and their significant others estimated a 38% and 43% (respectively) risk of cardiac arrest and a 92% and 87% likelihood of a successful resuscitation with the use of the AED. Subjects' perceived risk of cardiac arrest were subjectively related to their estimate of current health status, size of infarction, and symptoms during their MI. Subjects also related their estimates of risk to their likelihood of traveling with their AED and whether they would consider purchasing one. Significant others had high confidence in their ability to properly use the AED.

CONCLUSIONS

AEDs were valued highly by subjects and enhanced their perceived control over their heart disease. This was especially true for subjects who believed that their risk of cardiac arrest was high. The possible effects of providing education regarding expert estimates of the likelihood of cardiac arrest and of a successful resuscitation at the time of AED placement are discussed.

Sense of coherence and lack of control in relation to outcome after orthopaedic injuries

This study aimed to investigate whether sense of coherence (SOC) and lack of control are related to outcome after moderate orthopaedic injuries. One hundred and eleven patients with orthopaedic injuries were included. The patients were followed up 1 year after the injury (physical examination, Disability Raring Index (DRI), Visual Analogue Scale, Beck's Depression Inventory and SF-36). At a minimum of 2 years after the injury, the patients filled out a questionnaire, which included three SOC questions and one question about sense of lack of control. The results showed that a low sense of coherence, sense of having less control over one's life, and signs of depression were associated with an increased risk of having a less good clinical and functional outcome 1 year after the injury (odds ratios varied between 2 and 11). We conclude that these factors seem to be predictive of the outcome and should be taken into consideration when designing rehabilitation programs for injured patients.