Psychological, Social, and Functional Manifestations of Orthopaedic Trauma and Traumatic Brain Injury

Introduction

Psychological stress is a normal human emotion that can be associated with any disease or injury. Most individuals confronting a new diagnosis are able to understand, accept, and move forward. Their ability to do this requires personal inner resources, as well as the support and understanding of their healthcare providers, families, friends, and society. Musculoskeletal injuries often contribute to a gamut of anxiety and fears related to future function and ability to remain active in everyday life. Among the many concerns are disabilities secondary to loss of a limb and unrepairable musculoskeletal injury, disfigurement secondary to the musculoskeletal injury, distress over finances and the ability to return to work, concerns about sexual function, and the questionable likelihood of return to recreational activities. Patients frequently recover from the musculoskeletal injury uneventfully, but recovery from the psychological comorbidity is often far more difficult. Clinicians and researchers have largely considered psychological and physical injuries as distinct entities, but there is considerable evidence, both from military and civilian literature, that recovery from physical injuries is dramatically and adversely influenced by the presence of comorbidities such as depression, posttraumatic stress disorder (PTSD), and other psychological and psychiatric conditions.

It has become increasingly clear that orthopaedic surgeons must find a way to ensure that the psychosocial needs of their patient and their patient's family are adequately addressed in order to optimize the patient's functional recovery at home, work, recreationally, and in society. Learning to actively seek out the concerns of our patients and families, and validating and normalizing the common emotions associated with musculoskeletal injury, creates a healthier psychological and social environment to assist recovery. Levin describes her fears of not being able to ski after sustaining an open pelvic fracture. Her distress, which was evident in her mood, was identified only by inquiring why she appeared concerned. She expressed fear that she would never be able to ski again, and her mood immediately improved when she was informed that she would almost certainly be able to return to skiing. Active involvement of a patient's family and friends during and after the hospitalization fills in the imperative psychosocial support that can be supplied only by an individual's “loved ones,” and the orthopaedic surgeon should both encourage this involvement and guide the family in how they can be supportive. For those without a network of informal supports, making the connection to peer support becomes critical.

Orthopaedic surgeons need to be aware of the psychological and social sequelae associated with musculoskeletal injury. They should learn to recognize the signs and symptoms of psychosocial challenges being faced by their patients and to identify patients and family members in need of help from a professional mental health provider. This chapter will review our present understanding of the psychosocial comorbidities that are associated with musculoskeletal trauma, and it will describe how these disorders can complicate, and at times prevent, a successful functional recovery from trauma. We will review the present state of our understanding of these common psychological comorbidities as well as strategies to treat these conditions, with particular attention paid to the role of the orthopaedic surgeon.

Biomedical Versus Biopsychosocial Model of Medicine

The biomedical model of disease is based on a generally accepted belief among both patients and physicians that symptomatology (pain, general malaise, fever, etc.) is related to an identifiable chemical, physiologic, or structural abnormality that may or may not be correctable. Initially, when a patient presents with acute orthopaedic trauma, this is a relatively straightforward exercise. The patient has a grade IIIB open tibia fracture, and we are going to “cure” him or her by placing an intramedullary rod in the tibia and performing a gastrocnemius rotation flap and a split-thickness skin graft (STSG). Unfortunately, we have learned from the Lower Extremity Assessment Project (LEAP) and other studies that individuals with seemingly similar musculoskeletal injuries can have very disparate recoveries. Despite a presumption that the severity of the injury will predict the likelihood of a compromised functional recovery and prolonged disability, significant variations in a complete functional recovery are seen in individuals with both extremely severe musculoskeletal injuries as well as minor musculoskeletal injuries.

This observed dichotomy of successful treatment of an individual's disease (fracture) and recovery led Engel to describe and introduce the biopsychosocial model and practice of medicine. Borrell-Cario, et.al. propose strategies to implement Engel's biopsychosocial model to modern clinical practice. Engel believed that the biomedical model failed to recognize each patient's individuality and humanity. He observed that a patient's personality (individuality), along with the patient's social support structure, dramatically affected recovery. Clearly, science and scientific discovery comprise a major component in our dramatic successes in caring for the patient with multiple injuries. The ability to recognize human emotion and individuality in an individual's recovery from musculoskeletal trauma allows the orthopaedic surgeon to be a more effective “healer” and will also improve the successes achieved by orthopaedic surgeons.

This chapter reviews the expanding body of evidence of the effect of psychological and social comorbidities on recovery from musculoskeletal trauma and their association with the development of prolonged and permanent disability. Anxiety, posttraumatic stress, and depression are among the most common conditions that are frequently associated with physical trauma and dramatically affect an individual's recovery. Fortunately, most patients will not be diagnosed with these conditions, even in the face of significant physical injuries. However, studies have shown that even subclinical symptoms of emotional stress and anxiety, if not adequately addressed, can impact recovery. This chapter will also review our rapidly expanding understanding of both mild traumatic brain injury (mTBI) and more extensive traumatic brain injury (TBI), which often accompanies skeletal injury, especially in the military. It is important for the orthopaedic surgeon to understand how TBI can impact the functional recovery of patients.

Anxiety Disorders and Posttraumatic Stress

Acute anxiety symptoms are common after a physical injury, and acute stress disorder (ASD) is one of the initial psychological responses that may be diagnosed in the immediate aftermath of an injury. It is characterized by a sense of numbing or detachment, restlessness, anxiety, irritability, problems focusing or concentrating, flashbacks, and sleep disturbance. ASD is typically considered a short-term response to injury, with symptoms lasting between 2 and 30 days. A review of the literature found that signs and symptoms of ASD were identified in 23% to 45% of patients after physical trauma.

The anxiety disorder spectrum includes generalized anxiety disorder (GAD), panic disorder with and without agoraphobia, PTSD, obsessive-compulsive disorder (OCD), social anxiety disorder, and specific phobias. Of these, GAD, panic disorder, and PTSD are most likely to be related to physical injury. Overall, anxiety disorders are perhaps even more common than depression, and total direct and indirect costs are similar to those associated with depression.

Traumatic Brain Injury and Posttraumatic Stress Disorder

Many skeletal trauma patients also sustain a concomitant injury to the brain, although precise rates of co-occurrence are largely unknown. TBI can range from severe brain injuries with prolonged coma to a mild injury with no loss of consciousness (LOC) and transient dazed feeling or confusion in the aftermath of a blow to the head. Differentiation of TBI severity remains a matter of considerable debate, but the DoD and the VA consider mTBI to include those with no more than 30 minutes LOC, moderate TBI including those with more than 30 minutes LOC but no more than 24 hours, and severe TBI limited to those with more than 24 hours LOC. Other factors that can help to categorize TBI include the Glasgow Coma Scale ([GCS]; score of 13–15 is mild, 9–12 moderate, and less than 9 severe) and the duration of posttraumatic amnesia (less than 1 day is mild, 1–7 days moderate, more than 7 severe). Some reports claim that more than 280,000 service members have experienced TBI in Iraq or Afghanistan, at least 80% of which are believed to be mild cases. TBI is frequently labeled the “signature injury” of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). The clinical presentations of mTBI and PTSD are often indistinguishable from each other, featuring impaired sleep, decreased concentration, and other symptoms. There is also evidence that these two disorders have some shared pathophysiology. The frequent co-occurrence of mTBI and PTSD, as well as the overlap in symptoms, has resulted in a growing controversy regarding the relationship between the two disorders and the implications for diagnosis and treatment, especially among veterans returning from OEF and OIF. More research is clearly needed to better understand how mTBI impacts recovery from PTSD and how mTBI might influence the response to various therapies for PTSD.

A self-completed mail survey of 2235 US military personnel returning from Iraq and Afghanistan reported that 12% had a history consistent with mTBI, whereas 11% were positive for PTSD. Even when overlapping symptoms were removed from the PTSD score, PTSD was more closely related to residual TBI symptoms than anything else. A similar pattern is found in survivors of MVCs, indicating that postconcussive symptoms of mTBI may be mediated by the interaction of neurologic and psychological factors. Another study of MVC-related TBI found that 14% met criteria for ASD in the immediate aftermath of the TBI, and most of them went on to develop chronic PTSD, suggesting it was the psychological rather than physical impact that led to chronic symptoms. Mild TBI spectrum is particularly difficult to define because some of the persistent symptoms that have been attributed to mTBI, including headaches, dizziness, memory problems, irritability, and sleep problems, are often reported by those with PTSD and other psychological conditions, and those with persistent symptoms after TBI usually seem to meet criteria for a mood or anxiety disorder.

The diagnosis of mTBI is a clinical diagnosis that should be made by a neurologist or medical practitioner experienced with TBI. Evaluation should include a detailed history, physical and neurologic examination, and, most importantly, an assessment of cognitive function. The decision to obtain neuroimaging is based on the level of suspicion of skull fracture or intracranial hemorrhage. Clinically available neuroimaging (computed tomography [CT] or magnetic resonance imaging [MRI]) is not adequate to rule out mTBI, which is a clinical diagnosis. If a patient has persistent altered mental status, LOC, abnormal GCS score, focal neurologic deficit(s), or is clinically deteriorating, then neuroimaging should be obtained.

There is serious concern that reliance on self-reporting of symptoms to establish a diagnosis of mTBI is problematic and thus unreliable. This is both expected and obvious. After all, by definition, these patients are brain injured with alteration of consciousness and memory dysfunction. This is especially true of patients who suffer other severe injuries such as concomitant skeletal trauma. A recent report reviewed the reliability of mTBI diagnosis based on self-reported history of aberration of consciousness in patients suffering complex injuries requiring medical evacuation from the war theater. Patients diagnosed with mTBI had normal neuroimaging, higher Injury Severity Scale (ISS) scores, and longer lengths of stay than those without mTBI. Patients with higher ISS scores and longer lengths of stay are more likely at the time of injury to require pain medication and suffer from hypoxia, hypotension, metabolic derangement, and other conditions that could affect awareness and consciousness. Because these disorders can alter consciousness in the absence of TBI, their impact on the diagnostic criteria in patients with severe injuries, especially extremity trauma, cannot be ruled out, which renders the TBI diagnosis unreliable. The paradoxical finding that further supports this conclusion is that patients who reported LOC actually had a lower incidence of abnormalities on neuroimaging.

Findings from studies conducted at Walter Reed National Military Medical Center have led to similar conclusions. In these investigations, self-report of feeling dazed or confused at the time of injury captures large numbers of individuals who experience PTSD and depression related to blast exposure, regardless of whether there is any physical injury or PTSD. This is true also in civilian clinical practice. A study of hospitalized civilian trauma victims that compared 90 patients initially diagnosed with mTBI to 85 non–brain-injured trauma patients found identical rates of postconcussional syndrome (PCS) in both groups. These results suggest no relationship between the diagnosis of mTBI and subsequent PCS symptomatology; moreover, the strongest predictor of PCS was in fact a prior mood or anxiety disorder, with an odds ratio of 5.76.

Although many patients will recover fully after mTBI, some may develop PCS. The World Health Organization's (WHO) International Classification of Diseases, 10th edition (ICD-10) defines PCS as having a history of TBI with persistence for at least 3 months of three or more of the following eight symptoms: (1) headache, (2) dizziness, (3) fatigue, (4) irritability, (5) insomnia, (6) difficulty with concentration, (7) memory problems, and (8) intolerance of stress, emotion, or alcohol. However, some have questioned the utility of these criteria, and many experts in the field, and more recent literature, have instead categorized those with persistent symptoms as having complicated TBI.

Because the diagnosis of mTBI based on self-report is problematic, there is a broad effort to employ point-of-care screening tools. For these to be effective, it must first be recognized that most TBI patients are typically unaware that they are injured and thus do not seek medical attention. For this reason, it is incumbent on colleagues, leaders, coaches, and sideline officials to have heightened sensitivity that an individual may be at risk of having suffered an mTBI or concussion and to then institute screening, sometimes in the face of protestations by the victim that he or she is uninjured. There are a number of point-of-injury clinical screening tools available, such as the Standardized Assessment of Concussion (SAC) and Sports Concussion Assessment Tool, version 3 (SCAT3). The military uses the Defense and Veterans Brain Injury Center's (DVBIC) Military Acute Concussion Evaluation (MACE). Embedded in the MACE is the SAC. The MACE collects history and symptoms and uses the SAC to test four cognitive domains: orientation, immediate recall, concentration, and memory. By regulation through the DoD Directive-Type Memorandum (DTM) 09-033, which is a general order that affects all service members, the MACE is administered to any service member considered to be at risk of having suffered an mTBI. “At risk” is defined as involvement in a vehicle blast event, collision, or rollover, presence within 50 meters of a blast (inside or outside of a vehicle), a direct blow to the head, or witnessed LOC. If screening is positive, the victim is referred to an advanced medical provider for further evaluation and diagnosis.

Moderate to severe TBI is a life-threatening medical condition. Point-of-injury care is focused on the “ABCs” of airway, breathing, and circulation. A GCS score determination should be made. In the field, care focuses on maintaining oxygen saturation higher than 92%, partial pressure of oxygen (PO ₂ ) higher than 60 mm Hg, partial pressure of carbon dioxide (PCO ₂ ) at 40 mm Hg, and systolic blood pressure higher than 90 mm Hg. Hyperventilation is reserved for those patients who are exhibiting clinical signs of cerebral herniation. Rapid transport to the nearest Level I trauma center with neurosurgical and neurology critical care is essential. There, care is dictated primarily by neurology specialists if there is isolated TBI or by the general trauma surgery service if there are also complex injuries, including skeletal.

There is an elevated risk of developing depression or other psychiatric disorders among moderate to severe TBI survivors, similar to that with other serious medical conditions, such as stroke or myocardial infarction. Several studies demonstrate that at least one-quarter to one-half of those with TBI have major depression. However, moderate to severe TBI may, at least initially, provide some “protection” against the development of PTSD by obscuring the memory of the traumatic event. Further evaluation is necessary to better delineate the relationship between the severity of TBI and the risk of PTSD. In addition, it is important to emphasize the need for close attention to, and repeated formal assessment for, the potential evolution of PTSD symptoms as rehabilitation progresses and memory improves in individuals with moderate to severe TBI. A combination of serial neuropsychological testing, along with the use of validated instruments such as CAPS for PTSD, and Beck Depression Inventory or PHQ for depression, is advisable to best sort out improvement in TBI and potential onset of psychological disorders.

TBI and PTSD commonly occur together. Explosive blast patients who experience significant persistent and recalcitrant symptoms should have a thorough evaluation for PTSD and other psychological sequelae. This may be particularly beneficial to the individual patient because there are specific treatments for PTSD, depression, and related conditions. Hoge and colleagues identified a significant association between mTBI and psychiatric symptoms, including PTSD, in more than 40% of those who had LOC. These investigators noted that the high rates of physical symptoms reported by soldiers could be attributed to PTSD and depression. When these conditions were included in the analyses, there was no direct relationship between mTBI and physical health problems except for headache. It should be noted that the diagnosis for mTBI in this study was based on self-reporting of alteration of consciousness.

Magnetic resonance spectroscopy (MRS) may be better than traditional MRI for identifying mTBI and differentiating it from PTSD. A study by Hetherington and colleagues of veterans exposed to explosive blast and suffering persistent memory impairment associated with mTBI revealed decreased N-acetylaspartate (NAA)/choline (Ch) and NAA/creatinine (Cr) ratios in the anterior hippocampus when compared with patients exposed to blast but without these impairments. The hippocampus in affected TBI patients was also reduced in size. When compared with patients with PTSD, TBI patients had anterior hippocampus metabolic ratios that were significantly lower. PTSD patients exposed to blast had no difference in their anterior hippocampus NAA : Ch and NAA : Cr ratios when compared with blast-exposed patients who did not have PTSD. The metabolic ratios in the anterior hippocampus were also not different between blast patients with PTSD and PTSD patients with no blast exposure. Furthermore, these metabolic ratios did not vary with patients diagnosed with depression or anxiety.

Proper clinical management for mTBI begins with immediately removing the victim from further play or activity. This is to avoid reinjury before the brain has adequately recovered. An injury during the vulnerable period results in further compromised autoregulation of cerebral blood flow, rapid development of cerebral edema, intracranial hypertension (elevated intracranial pressure), and neurologic deterioration to coma and, possibly, death.

Mild TBI treatment begins by allowing the patient to rest with minimal cognitive burden. Symptoms are managed using evidence-based clinical practice guidelines. Unfortunately, there is presently no clinically available pharmacologic agent that will facilitate or hasten the brain's recovery from TBI.

Return to work and type of work are guided by clinical improvement. The DoD and the American Academy of Neurology's 2013 sports concussion guidelines each recommend that patients be prescribed rest without exposure to excess cognitive stimulation. Both physical and cognitive activities should be gradually increased as the patient tolerates, that is, without exacerbation of symptoms. When the patient can tolerate normal activities, then a provocative test can be performed. This provocative test is exertional physical activity (e.g., running) followed by cognitive testing. If the patient does not have recurrence of symptoms and performs well on testing, he or she may return to full play or work. Many states now have laws that require at least 24 hours’ recovery and written permission from a neurologist or other medical practitioner skilled in managing concussion before return to play or work.

Treatment of mTBI is symptoms-focused. In 2009, the US Department of Veterans Affairs in conjunction with the DoD published a set of clinical practice guidelines for the management of concussion and mTBI. These are evidence-based recommendations for which pharmacologic and nonpharmacologic options are provided for each major symptom. For example, headache is to be treated with acetaminophen or nonsteroidal antiinflammatory agents, insomnia with sleep hygiene and nonbenzodiazepine soporific agents acutely, dizziness with physical therapy, and so forth. The American Academy of Neurology's guidelines note that there is no specific treatment for accelerating or improving recovery from mTBI. The goals are to allow sufficient time for the brain to heal, to minimize risk of reinjury, and to treat symptoms.

Recovery from mTBI is a gradual process with the majority of the cognitive recovery occurring in the first 6 months; approximately 70% to 80% of individuals have few postinjury problems. However, the remaining 20% to 30% have impaired function from residual symptoms that are usually psychiatric. Although depression, anxiety, and behavioral problems are commonly identified after TBI, it is exceedingly difficult to discern whether persistent emotional and behavioral symptoms are directly related to the neurologic damage, a secondary reaction to the cognitive deficits of the injury, or a comorbid psychological complication of the trauma itself.

Belanger and colleagues conducted a meta-analysis that raises doubts that persistent postconcussive syndrome symptoms are attributable solely to the injury. This work revealed greater cognitive sequelae of mTBI in “convenience samples,” that is, those seeking medical care for their symptoms, and those involved in litigation, as opposed to unselected or prospective samples. Litigation in particular was associated with stable or worsening cognitive function over time, which is perhaps not surprising; whether subconscious or not, functional improvement would presumably lessen reimbursement from pending litigation, serving as a disincentive to recovery.

In contrast, the investigators also found that studies with unselected populations or prospective designs had no evidence of residual neuropsychological impairment 3 months after the injury. In an exception, one longitudinal study of veterans compared long-term neuropsychological outcomes in those with self-reported mTBI after a motor vehicle accident with outcomes in those who had a motor vehicle accident without TBI, and to another group that had not had an accident, at an average of 8 years after the accident. Comprehensive neuropsychological testing identified no significant differences between the three groups, although the authors argued that minor, borderline differences on the Paced Auditory Serial Addition Test (PASAT) and California Verbal Learning Test (CVLT) suggested potential subtle attentional problems in the mTBI population. Although this finding might indicate potential long-term adverse neuropsychological effects of mTBI, it is quite conceivable that such differences are entirely due to psychiatric comorbidity, which should be carefully assessed in any studies that evaluate the impact of mTBI. Regardless of the pathogenesis, it is clear that the residual emotional and behavioral changes have a significant impact on adjustment, including employment and social relationships. Several factors influence this adjustment, such as injury severity, social support, premorbid functioning, and coping styles. For example, coping strategies such as avoidance, wishful thinking, worry, and self-blame are associated with higher levels of depression and anxiety in TBI patients. Coping strategies are an area that can be targeted for treatment intervention.

There is an expectation that the military's social structure can assist soldiers who are struggling with poor concentration, attention, and memory. Having clear responsibilities, belonging to a group, and a defined chain of command can provide needed support and structure to a recovering mTBI patient. However, the military can also be relatively unforgiving of mistakes, forgetfulness, or have poor attention to detail, leading to soldiers receiving a counseling statement (i.e., an administrative warning) or an Article 15 (i.e., nonjudicial military discipline) for infractions related to their symptoms. This punitive response can lead to increased psychosocial stress, which exacerbates existing symptoms and may contribute to further maintenance of TBI symptoms. Rank structure can be an additional complication because military hierarchy demands more from those of higher rank. Anecdotally, some higher-ranking soldiers have reported trying to “pass” as though they are not having difficulties to preserve pride and to meet expectations they believe are being placed on them. Intervention research may also need to include specific education for military leaders in how to handle TBI symptoms in the workplace as more soldiers resume their military duties.