Results suggest that orthopedic trauma patients have a significant pain burden but are satisfied with pain treatment during the hospital stay. Efforts are needed to improve pain assessment and management and findings imply that addressing self-efficacy and depressive symptoms may decrease pain and increase satisfaction at hospital discharge. Brief educational interventions that incorporate pain coping skills and self-management techniques may be a feasible approach to improving self-efficacy in the acute care setting. Additional recommendations include routine hospital screening for depression and increased communication between surgeons and mental health providers to identify patients at high risk for unmanaged pain and facilitate provision of early mental health services.

Background There has been increasing evidence to support the importance of psychosocial factors to poor outcomes after trauma. However, little is known about the contribution of pain catastrophizing and fear of movement to persistent pain and disability. Questions/purposes Therefore, we aimed to determine whether (1) high pain catastrophizing scores are independently associated with pain intensity or pain interference; (2) high fear of movement scores are independently associated with decreased physical health; and (3) depressive symptoms are independently associated with pain intensity, pain interference, or physical health at 1 year after accounting for patient characteristics of age and education. Methods Of 207 eligible patients, we prospectively enrolled 134 patients admitted to a Level I trauma center for surgical treatment of a fracture to the lower extremity. Sixty percent of patients (80 of 134) had an isolated lower extremity injury and the remainder sustained additional minor injury to the head/spine, abdomen/thorax, or upper extremity. Pain catastrophizing was measured with the Pain Catastrophizing Scale, fear of movement with the Tampa Scale for Kinesiophobia, and depressive symptoms with the Patient Health Questionnaire. Pain and physical health outcomes were assessed with the Brief Pain Inventory and the SF-12, respectively. Assessments were completed at 4 weeks and 1 year after hospitalization. Multiple variable hierarchical linear regression analyses were used to address study hypotheses. One hundred ten patients (82%)

Objectives The purpose of this study was to determine whether pain at hospital discharge is associated with general health and depression and post-traumatic stress disorder (PTSD) at 1 year following traumatic orthopaedic injury. Methods This study prospectively enrolled 213 patients, 19 to 86 years of age, admitted to an Academic Level 1 trauma center for surgical treatment of a traumatic lower-extremity or upper-extremity orthopaedic injury. Pain at hospital discharge was measured with the Brief Pain Inventory. At 1 year follow-up, physical and mental health was assessed with the SF-12 and depressive and PTSD symptoms with the 9-item Patient Health Questionnaire (PHQ-9) and PTSD Checklist-Civilian Version (PCL-C), respectively. Cut-of scores of 10 on the PHQ-9 and 44 on the PCL-C classified patients as having depression or PTSD. Results 133 patients (62%) completed follow-up at 1 year. Responders and non responders did not differ significantly on baseline characteristics. Multivariable regression found that increased pain at discharge was significantly associated with depression (OR = 3.3; p < 0.001) and PTSD (OR = 1.4; p = 0.03) at 1 year, after controlling for age, education, injury severity score, and either depressive or PTSD symptoms at hospital discharge. Early postoperative pain was not a significant risk factor for long-term physical and mental health. Discussion Findings highlight the importance of early screening for uncontrolled postoperative pain to identify patients at high risk for poor psychological outcomes and who could benefit from more aggressive pain management. Results suggest early interventions are needed to address pain severity in patients with orthopaedic trauma.

Objective To examine: (1) differences in patient-reported outcomes, neuropsychological tests, and thalamic functional connectivity (FC) between patients with mild traumatic brain injury (mTBI) and healthy controls; (2) the longitudinal association between changes in these measures. Design Prospective observational case-control study. Setting Academic medical center. Participants Thirteen patients with mTBI (mean age = 39.3 years, 4 female) and 11 healthy, age and sex-matched control subjects (mean age = 37.6, 4 female) were enrolled. Interventions Not applicable. Main Outcome Measure(s) Resting-state FC (3T MRI scanner) was examined between the thalamus and the Default Mode Network (THAL-DMN), Dorsal Attention Network (THAL-DAN), and Frontoparietal Control Network (THAL-FPC). Patient-reported outcomes included pain (Brief Pain Inventory), depressive symptoms (Patient Health Questionnaire-9), post-traumatic stress disorder (PTSD Checklist), and post-concussive (Rivermead Post-Concussion Questionnaire) symptoms. Neuropsychological tests included the D-KEFS Tower test, Trails B, and Hotel task. Assessments occurred at 6 weeks and 4 months after hospitalization for patients with mTBI and at a single visit for controls. Results Student’s t-tests found increased pain and depressive, PTSD, and post-concussive symptoms, decreased performance on Trails B, increased THAL-DMN FC, and decreased THAL-DAN and THAL-FPC FC in patients with mTBI compared to healthy controls. Spearman correlation coefficient indicated that increased THAL-DAN FC from baseline to 4 months was associated with decreased pain and post-concussive symptoms (corrected p < 0.05). Conclusions Findings suggest that alterations in thalamic FC occur after mTBI and improvements in pain and post-concussive symptoms are correlated with normalization of thalamic FC over time.

Results suggest that fear of movement and catastrophizing are risk factors for poor long-term outcomes after traumatic injury. Prospective studies are warranted to test the fear-avoidance model and determine whether the model may be relevant for explaining the development of chronic pain and disability in trauma survivors. The identification of subgroups based on negative pain beliefs may have the potential to improve outcomes after traumatic injury.

Long-term cognitive impairment is highly prevalent in TICU survivors without intracranial hemorrhage as are psychologic difficulties. Injury severity, concussion status, and delirium duration were not risk factors for the development of neuropsychological deficits in this cohort. Individuals with moderately severe injuries seem to be as likely as their more severely injured counterparts to experience marked cognitive impairment and psychologic difficulties; thus, screening efforts should focus on this potentially overlooked patient group.

The findings suggest that physical therapists can feasibly implement cognitive-behavioral skills over the telephone and may positively affect outcomes after spine surgery. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the CBPT intervention. Clinical implications include broadening the availability of well-accepted cognitive-behavioral strategies by expanding implementation to physical therapists and through a telephone delivery model.

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