American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Early Screening for Psychosocial Risk and Protective Factors

Abstract

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons (AAOS) have developed Appropriate Use Criteria for the Early Screening for Psychosocial Risk and Protective Factors. Evidence and clinical expertise were used to develop criteria for addressing mental and social health opportunities to help people recover from musculoskeletal injuries to the extremity, spine, and pelvis. The criteria were developed by identifying observable symptoms and results of screening that suggest mental and social health challenges among patients with lower extremity trauma in clinical practice. The 32 patient scenarios and three interventions (evaluate for psychological distress, evaluate for social health opportunities, and evaluate coping and resilience strategies) were developed by the writing panel of clinicians who are specialists in mental and social health in musculoskeletal illness. Next, a separate, multidisciplinary, voting panel made up of specialists and nonspecialists rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as “appropriate” (median rating, 7 to 9), “may be appropriate” (median rating, 4 to 6), or “rarely appropriate” (median rating, 1 to 3). Notably, with a high level of agreement, the voting panel determined that interventions to address mental and social health were appropriate in all scenarios as follows: 86% were rated appropriate, 14% were rated possibly appropriate, and none were rated rarely appropriate.

Team Approach: Management of Mental Health in Orthopaedic Patients

“…Notably, 86% of potential screening interventions were rated as "appropriate," 14% were rated as "may be appropriate," and 0% were rated as "rarely appropriate" 31 . This indicates that experts in multiple medical fields recommend that orthopaedic surgeons always evaluate and screen for mental and social health 31 .…”

“…*DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and PTSD = posttraumatic stress disorder.†Excerpt from Piuzzi and Ring 31 .…”

Orthopedic Patients with Mental Disorder: Literature Review on Preoperative and Postoperative Precautions

“…Musculoskeletal injury can affect mental and social health depending on the severity of symptoms and the magnitude of self-reported activity limitations. 22) Patients can experience both stress and distress, as well as unhelpful cognitive bias about pain, such as fear of painful movement during recovery. They can experience sadness, anger, guilt, shock, and denial.…”

“…The American Academy of Orthopedic Surgeons reported that psychiatric problems, such as anxiety, depression, and posttraumatic stress disorder (PTSD), can affect clinical outcomes and should be evaluated after trauma. 22) …”

“…An interdisciplinary approach to identifying and addressing mental health problems (anxiety, PTSD, depression, and premorbid psychiatric conditions) and social health problems (smoking, low education level, lack of social support) can help restore health after musculoskeletal injuries. 22 44) A positive emotional state, confidence in exercise, and a return to daily routine are known as the basis for optimal recovery. 45) …”