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CE: Pain and Mental Health Symptoms After Traumatic Orthopedic Injury

Breazeale, Stephen PhD, MSN, BSN; Barrett, Stephanie MSN, BSN; Holland, William MSN, BSN; Webb, Megan MSN, BSN

Author Information
AJN, American Journal of Nursing: September 2022 - Volume 122 - Issue 9 - p 26-37
doi: 10.1097/01.NAJ.0000873444.48723.48

Whether the result of a motor vehicle collision, a work injury, or simply missing a step, people who sustain traumatic orthopedic injuries—injuries to any components of the musculoskeletal system, such as joints, bones, muscles, tendons, or ligaments—commonly experience postinjury symptoms associated with stressor-related disorders such as posttraumatic stress disorder (PTSD) and acute stress disorder (ASD).

Physical concerns such as restoring anatomy and optimizing physical function tend to be the focus of clinical care for survivors of traumatic orthopedic injuries, and both are important and necessary. Focusing solely on physical recovery, however, neglects the emotional needs of these patients. For example, a traumatic injury survivor may achieve optimal physical recovery after a motor vehicle collision while simultaneously developing anxiety symptoms so severe they prevent the survivor from getting into a car to drive to work.

Pain and mental health symptoms of traumatic orthopedic injury. Postinjury symptoms that are not specifically orthopedic in nature commonly occur after traumatic orthopedic injury, often exerting debilitating effects on survivors. Such symptoms include the following1-7:

  • the transition from acute to chronic pain
  • sleep disturbance
  • anxiety
  • depression and stressor-related disorders

Identifying and treating these symptoms in survivors is therefore a necessary part of comprehensive care.

Yet the Joint Commission requires only that pain be assessed and treated in acute care and outpatient settings.8 This is troubling given that, in addition to pain, symptoms of anxiety, depression, and PTSD are highly correlated with traumatic orthopedic injury and negatively associated with postinjury return to work5 and other activities survivors associate with recovery.1 Additionally, most traumatic orthopedic injury survivors are treated in EDs and released,9 which suggests they may have fewer interactions with the health care system during the acute period in which they should be screened for postinjury symptoms associated with stressor-related disorders.

The association between injury severity and psychological symptoms is unclear.6 For this reason, many survivors are never screened or treated for the psychological symptoms that commonly follow traumatic orthopedic injury. Nurses at all levels are well suited to address this gap in clinical practice by assessing injury survivors for these common postinjury symptoms—from ED admission to the final clinical visit before discharge.

In this article, we discuss symptoms associated with such stressor-related disorders as ASD and PTSD that are commonly experienced following traumatic orthopedic injury, how these symptoms present in traumatic orthopedic injury survivors, the instruments that can be used to screen survivors for each, and the pharmacological and nonpharmacological strategies used to treat them. (See Figure 1 for an algorithm to guide the assessment of patients following traumatic orthopedic injury.)

F1-25
Figure 1.:
Algorithm for Assessment and Management of Traumatic Orthopedic Injury Symptoms

COMPREHENSIVE ASSESSMENT

Although we discuss each symptom individually, traumatic orthopedic injury survivors are likely to experience symptoms in combination,4 which exerts a synergistic effect on survivors' long-term outcomes. For example, one study of work and functional outcomes after 12 months in survivors of traumatic injury found that, compared with survivors who had neither depression nor PTSD, survivors with either depression or PTSD were three times less likely to have returned to work, and survivors with both were five to six times less likely to have returned to work.10 We thus recommend screening all traumatic orthopedic injury survivors for each of the symptoms described below to ensure comprehensive assessment of their postinjury mental as well as physical state. (For a summary of screening instruments and treatment options, see Table 1.11-26)

Table 1. - Summary of Screening Instruments and Symptom Management Strategies11-26
Symptom Instruments No. of Items Nonpharmacological Treatments Pharmacological Treatments
Anxiety
  1. Hospital Anxiety and Depression Scale–Anxiety

  2. Beck Anxiety Inventory

  3. PROMIS Anxiety–CAT

  4. PROMIS Anxiety–Short Form

  1. 7

  2. 21

  3. Up to 29

  4. 4, 6, 7, or 8

  1. Breathing techniques

  2. Mindful meditation

  3. Music therapy

  4. CBT

  1. SSRIs

  2. SNRIs

  3. Pregabalin

  4. Benzodiazepines

Depression
  1. Hospital Anxiety and Depression Scale

  2. Patient Health Questionnaire–2

  3. PROMIS Depression–CAT

  4. PROMIS Depression–Short Form

  1. 7

  2. 2

  3. Up to 28

  4. 4, 6, or 8

  1. Mindfulness-based CBT

  2. Psychotherapy

  3. Counseling

  1. SSRIs

  2. TCAs

  3. MAOIs

Pain
  1. Numeric Rating Scale

  2. PROMIS Pain Intensity

  3. PROMIS Pain Quality–Neuropathic and Nociceptive

  1. 11

  2. 1 or 3

  3. 5 each

  1. RICE

  2. TENS

  3. CBT

  4. Exercise therapy

  5. Massage

  6. Acupuncture

  1. Acetaminophen

  2. NSAIDs

  3. COX-2 inhibitors

  4. Anticonvulsants

  5. SSRIs

  6. TCAs

  7. Opioids

Sleep Disturbance
  1. Pittsburgh Sleep Quality Index

  2. PROMIS Sleep Disturbance–CAT

  3. PROMIS Sleep Disturbance–Short Form

  1. 19

  2. Up to 27

  3. 4, 6, or 8

Sleep hygiene
  1. Melatonin

  2. Benzodiazepines

  3. Hypnotics

Stressor-Related Disorders
  1. Acute Stress Disorder Scale

  2. PTSD Checklist for DSM-5

  3. Primary Care PTSD Screen for DSM-5

  1. 19

  2. 20

  3. 5

  1. CBT

  2. CPT

  3. Prolonged exposure

  4. EMDR

  1. SSRIs

  2. SNRIs

CAT = computer adaptive test; CBT = cognitive behavioral therapy; COX-2 = cyclooxygenase 2; CPT = cognitive processing therapy; DSM-5 = Diagnostic and Statistical Manual, 5th edition; EMDR = eye movement desensitization and reprocessing; MAOI = monoamine oxidase inhibitor; NSAID = nonsteroidal antiinflammatory drug; PROMIS = Patient-Reported Outcomes Measurement Information System; PTSD = posttraumatic stress disorder; RICE = rest, ice, compression, elevation; SSRI = selective serotonin reuptake inhibitor; SNRI = serotonin–norepinephrine reuptake inhibitor; TCA = tricyclic antidepressant; TENS = transcutaneous electrical nerve stimulation.

PAIN IN TRAUMATIC ORTHOPEDIC INJURY

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”27 Pain in traumatic orthopedic injury may be acute or chronic: both are highly prevalent in survivors.2, 3 The International Classification of Diseases, 11th Revision for Mortality and Morbidity Statistics, defines acute pain as “pain with a duration of less than three months” and chronic pain as “pain that persists or recurs for longer than three months,” noting that chronic pain is multifactorial, with biological, psychological, and social contributing factors.28

Studies suggest that 48% to 69% of traumatic orthopedic injury survivors report moderate to severe acute pain at the time of hospital discharge, and up to 86% report chronic pain for at least six months after injury.2 Risk factors for developing chronic pain after traumatic orthopedic injury include the following3:

  • high-intensity acute postinjury pain
  • female sex
  • age 65 or older
  • less than a college education
  • low socioeconomic status
  • severe lower extremity injuries

Assessing pain. All patients receiving care in acute or outpatient settings, including traumatic orthopedic injury survivors, should be assessed and treated with multimodal therapies for pain. Ideally, pain should be assessed both at rest and during activity.29

Nursing assessment should address the following aspects of pain, noting any factors that may affect accuracy, such as language barriers or cognitive issues29:

  • onset
  • pattern
  • location
  • quality
  • intensity
  • aggravating and relieving factors
  • previous treatments
  • effects on physical function, emotional health, and sleep

Pain is subjective, and the American Pain Society's Guidelines on the Management of Postoperative Pain stress the importance of assessing pain regularly and respecting patients' self-reports of pain.29

The 11-point numeric rating scale is a validated assessment tool commonly used to determine pain incidence, intensity, and duration after orthopedic extremity trauma.2, 11, 29 Nurses using this tool ask patients to rate the intensity of their pain with a number from 0 (representing “no pain”) to 10 (representing “worst possible pain”).11

The Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity instrument can be administered to adults (over age 18), children (self-report, ages eight to 17), and parents acting as proxy for their children.12 PROMIS Pain Intensity is available as a single-item 0—10 numeric rating scale. The instruments are available in long and short forms.

The five-item adult PROMIS Pain Quality instrument can be used to assess whether an adult's pain is neuropathic (caused by peripheral somatosensory nerve injury that produces sensations described as tingly, stinging, or electrical in quality) or nociceptive (caused by stimulation of peripheral nerve fibers that produces sensations described as tender, aching, deep, or sore).13

Treating pain. Although both nonpharmacological and pharmacological options are available for managing the pain of orthopedic trauma, the Centers for Disease Control and Prevention recommends that nonpharmacological treatments (as well as nonopioid pharmacological treatments) be used as first-line therapy for managing chronic pain.30 The Joint Commision recommends that pain management include nonpharmacological or pharmacological therapies, or both.31

Rest, ice, compression, and elevation (RICE) are the foundational elements of nonpharmacological orthopedic pain management.32 Together, RICE therapies limit use of affected extremities, decrease inflammation, and promote lymphatic drainage.32 Other nonpharmacological treatments, such as transcutaneous electrical nerve stimulation, cognitive behavioral therapy (CBT), exercise therapy, massage, and acupuncture can be used in conjunction with RICE therapies for additional pain control.29 The choice of nonpharmacological pain management strategies should align with patient preferences.30, 31

When pharmacological treatments are needed, nonopioid medications should be considered first.30 If opioid treatment is prescribed, it should be combined with nonopioid pharmacological treatments, including acetaminophen; nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and cyclooxygenase 2 (COX-2) inhibitors; and nonpharmacological therapies, such as CBT, physical therapy, and exercise therapy.30, 33

It should be noted that some animal studies have found COX-2 production of prostaglandins to play an important role in the process of fracture healing, and, in humans, reduced expression of prostaglandins has been associated with fracture nonunion. The association between fracture healing and prostaglandins has raised concerns about using COX-2 inhibitors as well as nonselective NSAIDs, which inhibit both COX-1 and COX-2, to treat pain in people with orthopedic fractures since, theoretically, both may increase the risk of nonunion.34 For this reason, some orthopedists caution patients not to use these drugs during the acute phase of fracture healing.35 Nevertheless, these drugs' effects on fracture healing remains controversial and requires further study.34, 35 Anticonvulsants, such as pregabalin and gabapentin, and antidepressants, such as tricyclic antidepressants and serotonin–norepinephrine reuptake inhibitors (SNRIs), are effective in treating neuropathic pain.29, 30

If nonpharmacological and nonopioid medications are insufficient to manage the survivor's pain, opioid medications, such as morphine and oxycodone, which act as agonists of endogenous opioid peptides and bind to the opioid receptors in the central nervous system (CNS), thereby inhibiting the person's perception of pain, can be used.30, 36

When initiating opioid therapy or titrating dosages, monitor patients for adverse effects.29 Keep in mind that patients should not concurrently use benzodiazepines with opioid medications to avoid potentially lethal CNS depression.30

In addition to common adverse effects of opioids, such as drowsiness, hypotension, nausea, and constipation, opioid medications can also cause respiratory depression, coma, and death.36

Clinicians treating traumatic orthopedic injury survivors who are taking high doses of opioids—such as 50 morphine milligram equivalents or more per day—to manage their pain may consider simultaneously prescribing intranasal naloxone and cautioning survivors who have used benzodiazepines in the recent past about the dangers of concurrent benzodiazepine and opioid use.30

The efficacy of opioids in treating chronic pain is not well established,30 and prolonged use of opioids may result in dependence and tolerance.36 So when prescribing opioid therapy for traumatic orthopedic injury survivors as part of a multimodal approach to pain management, minimize the risk of opioid use disorder and overdose by prescribing the lowest opioid dose for the shortest period, in conjunction with other pain management strategies.30

SLEEP DISTURBANCE

Sleep disturbances, including issues with the quality, depth, and restoration of sleep,15 are common postinjury symptoms experienced by traumatic orthopedic injury survivors, with most reporting sleep disturbances during their initial hospitalizations7, 37, 38 that may continue for many months thereafter.7 Even one year following injury, as many as 18% of survivors report sleep disturbances.39

Risk factors for sleep disturbance after traumatic orthopedic injury include the following7, 39, 40:

  • female sex
  • greater injury severity
  • greater pain
  • poor mental health
  • high energy mechanism of injury
  • impairment in activities of daily living

Assessing sleep disturbance. The Pittsburgh Sleep Quality Index (PSQI)14 and the PROMIS Sleep Disturbance15 instrument are commonly used to identify sleep disturbances across patient populations.

The PSQI is a 19-item self-report instrument that examines the quality of a person's sleep across seven domains associated with poor sleep: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction.14

The PROMIS Sleep Disturbance instrument consists of 27 potential items and may be administered in one of two ways: using a computer adaptive test (CAT) or in a short form, including four, six, or eight standard items.15

The instrument asks patients to rate their agreement on a scale of 1 (“very much”) to 5 (“not at all”) with such statements as “My sleep was refreshing,” “I had a problem with my sleep,” and “I had difficulty falling asleep.”15

Treating sleep disturbance. The treatment of sleep disturbances involves sleep hygiene and may include pharmacological interventions.

Sleep hygiene is a nonpharmacological means of promoting good sleep habits by addressing the following factors that affect the quality of a person's sleep26:

  • sleep rhythm (maintaining consistent sleep and wake times)
  • environment (sleeping in a quiet, dark bedroom that is kept at a comfortable temperature and has no distractions, such as a TV, radio, or computer)
  • personal habits (avoiding naps, having no caffeine within six hours of bedtime, staying out of bed until drowsy, and getting regular exposure to sunlight)

Promoting sleep hygiene can be challenging in the hospital. In one clinical audit, the majority of traumatic orthopedic injury survivors reported that their sleep was largely impaired by noise, as well as by light, pain, temperature, and routine observations.37 Fewer than one-third of survivors reported receiving assistance with sleep hygiene, for example, by being given a sleep mask or ear plugs, pain relief, or sleep medication, and only 9% reported that observation or medication routines were modified.37

Nurses are uniquely suited to promote sleep hygiene within their patient care units by modifying the unit environment and tailoring patient care plans to minimize disruptions throughout the night. Small changes in the environment and in patient care plans may have a large impact on traumatic orthopedic injury survivors' sleep.

Pharmacological therapy may be prescribed to survivors who require intervention beyond improved sleep hygiene. Medications include melatonin, short-acting benzodiazepines such as triazolam and temazepam hypnotics in select cases, and melatonin agonists.25, 41 Melatonin is a naturally occurring hormone with hypnotic, antioxidant, and immunomodulatory properties that is secreted at night by the pineal gland, which controls the sleep—wake cycle.41 When endogenous melatonin levels are low, administering 10 mg of exogenous melatonin has been found to improve sleep quality and duration.41

Hypnotics, like zolpidem and eszopiclone, induce sleep via CNS depression produced through their binding to γ -aminobutyric acid (GABA) receptors.36 Both benzodiazepines and hypnotics should be taken only at bedtime and only used for short periods.25 The American Geriatrics Society Beers criteria further recommend against using benzodiazepines to treat insomnia in older patients due to risks of cognitive impairment, falls, and motor vehicle accidents.42

The benefits and risks of all medications should be weighed before prescribing them for a traumatic orthopedic injury survivor. Benzodiazepines and hypnotics may be more effective in treating sleep onset and sleep maintenance insomnia than melatonin.25 Both benzodiazepines and hypnotics should be used with caution in patients receiving other CNS depressants,30 such as opioids, and patients receiving them should be monitored for signs of dependence and/or misuse.36, 43 Benzodiazepines and hypnotics also meet the Beers criteria and should not be prescribed in patients ages 65 or older.36, 42 In contrast, melatonin has few adverse effects and lowers the risk of postoperative delirium.44, 45 Even when provided medication to treat sleep disorders, comprehensive treatment of traumatic orthopedic injury survivors requires that they be taught sleep hygiene strategies.26

ANXIETY

Anxiety is defined by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as “the anticipation of a future threat.”46 Excessive worry that is difficult to control is the hallmark symptom of anxiety.46 Other symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.46 Symptoms of anxiety are highly prevalent after traumatic orthopedic injury and often become chronic in nature. As many as 55% of traumatic orthopedic injury survivors report clinically significant anxiety symptoms immediately after injury, 40% report such symptoms one year after injury, and 20% continue to experience them 10 years after injury.4 Risk factors for anxiety symptoms after traumatic orthopedic injury include the following:

  • self-identified African American race47
  • female sex47
  • spine injuries48
  • decreased physical function48
  • higher pain intensity49

Assessing anxiety symptoms. Several instruments can be used to identify traumatic orthopedic injury survivors with clinically significant anxiety symptoms.

The Hospital Anxiety and Depression Scale (HADS)18 and the HADS anxiety subscale (HADS-A)16, 18 ask respondents how they are feeling at the time of assessment. Items on the HADS-A include “I feel tense or ‘wound up’” and “I get sudden feelings of panic.”18

The Beck Anxiety Inventory (BAI) uses a seven-day recall period and assesses somatic symptoms of anxiety such as dizziness and an inability to relax.16 Of note, unlike the other instruments described here, the BAI is proprietary, and users must purchase a license from Pearson Assessments to use it in clinical or research settings.16

The PROMIS Anxiety instrument can be administered either as a 29-item CAT or as a four-, six-, seven-, or eight-item short form.17

Treating anxiety symptoms. Anxiety symptoms require a multimodal approach consisting of pharmacological and nonpharmacological interventions.

Breathing techniques,50 mindfulness meditation,51 and music therapy52 are complementary treatments shown to reduce anxiety symptom severity in orthopedic patient populations. A short breathing exercise, consisting of six cycles of inhaling through the nose for four seconds, holding the breath for three seconds, and then exhaling through the mouth for four seconds, practiced four times daily (morning, afternoon, night, and bedtime) is effective at reducing anxiety symptoms.50 Mindfulness meditation practiced by traumatic orthopedic injury survivors promotes acceptance of their physical state and helps them achieve emotional self-regulation by encouraging them to reflect nonjudgmentally on their internal experiences (that is, their physical sensations and thoughts).51 Music therapy, commonly using music selected by the participant, reduces anxiety symptoms by distracting from the participant's negative internal experience by replacing it with a positive external stimulus.52

If a traumatic orthopedic injury survivor requires formal, clinician-administered psychotherapy for their anxiety symptoms, CBT is the gold standard.53 The goal of CBT is to help survivors recognize and change maladaptive thoughts about potential threats through cognitive restructuring and behavioral techniques such as exposure therapy and relaxation training.54 CBT is highly effective and has been shown to produce sustained results. One meta-analysis found that patients with anxiety disorders who underwent CBT for their anxiety symptoms were three times more likely to go into remission than those treated with either placebo therapy or medication.53, 55

Several categories of medications can be used to effectively treat anxiety symptoms in traumatic orthopedic injury survivors. Selective serotonin reuptake inhibitors (SSRIs) and SNRIs are recommended as first-line drug treatment for anxiety symptoms.56 Pregabalin can be used instead if SSRIs and SNRIs are not tolerated.56 The SSRIs paroxetine and sertraline inhibit reuptake of synaptic serotonin, which allows serotonin to continue to signal within the CNS.36 Similarly, SNRIs, such as venlafaxine and duloxetine, inhibit reuptake of serotonin and norepinephrine.36 Pregabalin binds to calcium channels at nerve terminals within the CNS, modulating neurotransmitter release.36 The therapeutic effects of SSRIs and SNRIs are generally reached two to four weeks after initiating therapy, while the therapeutic effects of pregabalin are reached within days of beginning treatment.57

Benzodiazepines, such as diazepam and lorazepam, which depress the CNS by potentiating the inhibitory neurotransmitter GABA, are controversial in the management of anxiety symptoms, thus they should be prescribed with caution and their use should be time-limited if they are needed to manage a traumatic orthopedic injury survivor's anxiety symptoms.36, 56, 57 Their sedative effects may impair cognitive function and prolonged use can lead to dependence or misuse.36

The treatment of anxiety symptoms should be based on the severity of a traumatic injury survivor's symptoms and be customized to their preferences.56 Some survivors may be able to manage their anxiety symptoms with breathing exercises and music therapy, while others may require more intensive psychotherapeutic and pharmacological therapy under the direction of a trained clinician. Regardless, the concomitant use of multiple techniques is recommended to comprehensively address anxiety symptoms.57

RECOGNIZING DEPRESSION

Depressed mood is the hallmark symptom of depression, but others include a lack of interest or pleasure in daily activities, sleep disturbances, fatigue, feeling worthless, difficulty concentrating, psychomotor agitation, and suicidal ideation.46 Traumatic orthopedic injury survivors often begin to develop depressive symptoms immediately after injury, with up to 44% reporting clinically significant depressive symptoms within the first three weeks of injury.6 Depressive symptoms commonly persist. More than 27% of survivors report clinically significant depressive symptoms six years after injury.6 In one study, 27% of depressive symptoms were associated with poor outcomes among survivors, including the failure to return to work.5

Risk factors for depressive symptoms after traumatic orthopedic injury include the following4, 58-60:

  • female sex
  • increased pain
  • injury is recent (depressive symptoms are most prevalent within one month of injury and significantly less so at subsequent follow-up)
  • intentional injury
  • advanced age

Assessing depressive symptoms. The HADS,18 two-item Patient Health Questionnaire (PHQ-2),19 and PROMIS Depression instrument can all be used to screen traumatic orthopedic injury survivors for depressive symptoms.

The HADS-D, or depression subscale of the HADS, consists of seven items that assess the severity of a person's depressive symptoms over the previous week.18 Example items include “I still enjoy the things I used to enjoy” and “I have lost interest in my appearance.”18

The PHQ-2 assesses the severity of a person's depressive symptoms over the past two weeks.19 The two items on the PHQ-2 are “little interest or pleasure in doing things” and “feeling down, depressed, or hopeless.”19

The PROMIS Depression instrument assesses a person's negative mood, views of self, social cognition, and decreased positive affect and engagement over the last seven days.17 The PROMIS depression instrument is available in four-, six-, and eight-item standard forms and a CAT that includes as many as 28 items.17

Suicidal ideation is common among those with depressive symptoms.45 However, as neither of these three instruments screens individuals for suicidal ideation, traumatic orthopedic injury survivors with depressive symptoms should be screened using other means and treated for suicidal ideation as appropriate.61

Treating depressive symptoms. Depressive symptoms can be managed through a variety of nonpharmacological and pharmacological interventions, though they are best treated through interventions administered by trained clinicians.62 Formal intervention by trained clinicians is recommended as first-line therapy for mild depressive symptoms.61

CBT, mindfulness-based CBT, and other forms of psychotherapy have all been found to be effective in mitigating depressive symptoms in trauma survivors.62 Although these interventions require a formally trained clinician, web-based options make such interventions more accessible to traumatic orthopedic injury survivors and are highly effective in mitigating depressive symptoms. For example, patients with back pain who received web-based CBT were found to be 52% less likely to report clinically significant depressive symptoms than those who did not (hazard ratio, 0.48; 95% CI, 0.28-0.81, P < 0.001).63

Traumatic orthopedic injury survivors with moderate to severe depressive symptoms should be prescribed pharmacological therapy.61 SSRIs are widely recommended as the drug of choice for treating depressive symptoms.61 Other medications, such as tricyclic antidepressants (TCAs), which act by increasing the effect of serotonin, norepinephrine, and monoamine oxidase inhibitors (MAOIs), can be used when SSRIs have failed.36, 61 TCAs and MAOIs, however, should be used with caution as they have more adverse effects and potential drug–drug and drug–food interactions than SSRIs.36

Once started, the effects of antidepressant medications will not be felt for at least two weeks.36 In addition, patients starting antidepressant therapy should be effectively treated for at least six months before attempting to wean off or discontinue treatment.61 Any patient receiving pharmacological therapy for depressive symptoms should also receive formal nonpharmacological therapy from a trained clinician.61

STRESSOR-RELATED DISORDERS

Both ASD and PTSD occur after exposure to an event that caused or threatened serious harm or death, and both disorders are marked by specific symptoms across five domains—intrusion, negative mood, dissociation, avoidance, and arousal—that begin or worsen after the traumatic event.46

Symptoms of ASD begin immediately after the event and may persist for up to one month, while PTSD is marked by symptoms that begin or persist more than one month after the event.46

Unsurprisingly, symptoms of stressor-related disorders are common among traumatic orthopedic injury survivors. In a recent meta-analysis, the mean pooled prevalence of PTSD was 29.1% among civilian survivors of traumatic orthopedic injury and 26.9% among military personnel.6 The mean pooled prevalence of depression was 36.2% in the first six months and 26.7% more than two years after the injury.6

Risk factors for symptoms of stressor-related disorders after traumatic orthopedic injury include the following6, 58, 60:

  • female sex
  • less than a high school education
  • lower-extremity injury
  • increased pain
  • intentional injury

Assessing symptoms of stressor-related disorders. Traumatic orthopedic injury survivors should be screened for stressor-related symptoms using a validated instrument.

The Acute Stress Disorder Scale (ASDS)20 is a 19-item civilian version of the Posttraumatic Stress Disorder Checklist (PCL), which asks respondents about PTSD symptoms they have experienced over the past month.21 With the ASDS, a person reports the degree to which they have experienced stressor-related symptoms on a five-point scale, ranging from 1 (not at all) to 5 (very much).20

The PCL for DSM-5 (PCL-5) and the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)—revised versions of the PCL and the PC-PTSD that reflect changes to PTSD criteria in the DSM-5—should be used to assess stressor-related symptoms in traumatic orthopedic injury survivors who are more than one month removed from injury.21, 22 The PCL-5 consists of 20 items that examine the degree to which a person experiences symptoms of PTSD, such as flashbacks, emotional numbing, and amnesia.21 Alternatively, the PC-PTSD-5 is a five-item instrument that can quickly identify survivors who are experiencing clinically significant stressor-related symptoms.22 Each item corresponds to one of the five diagnostic domains of PTSD as well as to another domain that focuses on feelings of guilt or blame related to the traumatic events.22 Those being assessed are asked to indicate (yes or no) the presence or absence of the given symptom.

Treating symptoms of stressor-related disorders. Nonpharmacological treatment of stressor-related symptoms is best accomplished with clinician-administered trauma-focused psychotherapies that emphasize the memory and meaning of the traumatic event, such as CBT, cognitive processing therapy (CPT), prolonged exposure, and eye movement desensitization and reprocessing (EMDR).23, 24 Through CPT, survivors learn how to recognize and change their negative thoughts and feelings related to the trauma.23 Prolonged exposure therapy teaches survivors to address their thoughts and feelings about the trauma, encouraging them to talk about it until the memories seem less intense.23 Survivors treated with EMDR focus on repetitive sounds or track the therapist's finger moving back and forth before their eyes when discussing the event to help them process and make sense of their memories.23

Although medications may be used as monotherapy for stressor-related disorders, they are best used in combination with trauma-focused psychotherapies.23 The SSRIs fluoxetine, sertraline, and paroxetine, and the SNRI venlafaxine are recommended by the American Psychological Association for managing stressor-related symptoms.24 As with medications for depressive symptoms, the effects of medications for stressor-related symptoms may not be felt for several weeks after treatment begins.36 Survivors treated for stressor-related symptoms should be routinely assessed for potential suicidality while receiving treatment.24

IDENTIFYING SURVIVORS WITH SYMPTOMS OF STRESSOR-RELATED DISORDERS

Two factors are key in helping nurses recognize symptoms of stressor-related disorders in traumatic orthopedic injury survivors: knowledge of the risk factors for the disorder and knowledge of the validated instruments used for formal screening. Let's think through two potential scenarios and consider how this knowledge facilitates early patient identification.

Patient scenarios. First, imagine Jane. She is a 61-year-old woman on the surgical unit who was admitted with severe lower-extremity trauma after being struck by a car while crossing the street. Her pain is poorly controlled despite the administration of IV opioids.

Next, picture John, a 27-year-old man seen in the outpatient clinic four months after fracturing his right humerus in a fall from a ladder. John's pain has mostly resolved and is well controlled on nonopioid medications. He attends physical therapy three times per week and is regaining his strength and mobility.

Risk factors. Jane's risk factors for postinjury stressor-related disorder include female sex, advanced age, a high-energy mechanism of injury, proximity to the event, decreased physical function, severe lower-extremity injury, and high levels of pain, putting her at high risk for multiple symptoms of postinjury stressor-related disorder.

John, on the other hand, has only two risk factors: a high-energy mechanism of injury and a moderate to severe injury. Therefore, John is at lower risk for symptoms of postinjury stressor-related disorder than Jane.

The need to screen. You might think that only Jane needs to be screened for stressor-related disorder because she is at highest risk. However, having fewer risk factors doesn't necessarily preclude the development of symptoms, as each traumatic orthopedic injury survivor's experience is unique. Both Jane and John should be screened for symptoms of stressor-related disorder—such as anxiety, depression, pain, and sleep disturbance—to ensure positive postinjury outcomes.

Administering multiple instruments may seem impractical in practice settings like an ED or outpatient clinic and may be burdensome for patients. However, to prioritize administration time and reduce participant burden, nurses may choose validated instruments with fewer items, such as the PROMIS short forms to assess patients for symptoms of anxiety, depression, pain, and sleep disturbance, and the five-item PC-PTSD-5,22 to quickly identify survivors who are experiencing clinically significant stressor-related symptoms.

If time allows, or if a more comprehensive assessment is required, nurses may conduct a more inclusive assessment using instruments such as the HADS or HADS-A16, 18 and the PCL-5.21

Experiencing a traumatic injury and being in a foreign setting, whether an ED, a hospital unit, or an outpatient clinic, may make traumatic orthopedic injury survivors reluctant to share their experiences. Nurses play a significant role in creating an environment in which survivors can feel comfortable discussing potentially sensitive issues, such as postinjury symptoms of anxiety or depression. Nurses should provide survivors with privacy and the opportunity to voice concerns without judgment.64 Nurses should also ask open-ended questions to clarify ambiguous answers to any items on the screening instruments used.64

Traumatic orthopedic injury survivors who screen positive for clinically significant levels of a stressor-related disorder symptom should be referred promptly to trained clinicians for formal evaluation and treatment.64

If a survivor is reluctant to seek treatment, nurses can attempt to put them at ease by explaining, for example, that further evaluation is not treatment, that treatment is optional, and that the decision to pursue treatment rests solely with the survivor.64

Potential treatments. Nurses should describe potential treatments, which include nonpharmacological and pharmacological modalities, as this can help survivors make informed decisions about their care.64 Nurses can initiate many nonpharmacological interventions that require no special training. These include

  • teaching survivors breathing exercises that can reduce anxiety symptoms.
  • discussing sleep hygiene, which can continue to promote sleep after hospital discharge.
  • implementing RICE therapies to assist with pain management.
  • providing aids such as earplugs and eye masks that may make the survivor's environment more conducive to sleep.
  • asking if more blankets or pain medication is needed.

Given that postinjury symptoms of stressor-related disorders are often chronic, nurses should rescreen traumatic orthopedic injury survivors for symptoms at regular intervals throughout their recovery.64 Doing so will help the health care team adapt survivors' care plans by identifying those survivors whose symptoms have resolved, continued, or worsened, as well as those who have developed new symptoms after screening negative in the past, all of which may promote positive long-term outcomes, such as returning to work and increasing health-related quality of life.

THE CHALLENGE FOR NURSES AND HEALTH CARE FACILITIES

Symptoms of stressor-related disorders, such as anxiety, depression, pain, and sleep disturbance, are common among traumatic orthopedic injury survivors. Such symptoms often present comorbidly, increasing their effect on survivors' long-term outcomes. Routinely screening survivors for such postinjury symptoms and, when present, referring them for formal evaluation and treatment ensures that they receive comprehensive postinjury care. Nurses play a key role in ensuring that such postinjury symptoms are identified and treated and can, in many cases, initiate nonpharmacological therapies to minimize symptom burden in survivors. We challenge nurses and health care facilities to examine their practices and identify ways in which they can implement routine screening and treatment for postinjury symptoms of stressor-related disorders in traumatic orthopedic injury survivors. Doing so promotes not only physical healing, but also emotional and psychological healing in these survivors.

REFERENCES

1. Aitken LM, et al. Indicators of injury recovery identified by patients, family members and clinicians. Injury 2016;47(12):2655–63.
2. Bérubé M, et al. Acute to chronic pain transition in extremity trauma: a narrative review for future preventive interventions (part 1). Int J Orthop Trauma Nurs 2016;23:47–59.
3. Bérubé M, et al. Acute to chronic pain transition in extremity trauma: a narrative review for future preventive interventions (part 2). Int J Orthop Trauma Nurs 2017;24:59–67.
4. Breazeale S, et al. Anxiety symptoms after orthopedic injury: a systematic review. J Trauma Nurs 2021;28(1):46–55.
5. Giummarra MJ, et al. Return to work after traumatic injury: increased work-related disability in injured persons receiving financial compensation is mediated by perceived injustice. J Occup Rehabil 2017;27(2):173–85.
6. Muscatelli S, et al. Prevalence of depression and posttraumatic stress disorder after acute orthopaedic trauma: a systematic review and meta-analysis. J Orthop Trauma 2017;31(1):47–55.
7. Swann MC, et al. Sleep disturbance in orthopaedic trauma patients. J Orthop Trauma 2018;32(10):500–4.
8. Joint Commission. Pain assessment and management—understanding the requirements. Oakbrook Terrace, IL; 2021 Oct 19. https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/provision-of-care-treatment-and-services-pc/000002161.
9. Centers for Disease Control and Prevention. WISQARS nonfatal injury visualization. 2020. https://wisqars.cdc.gov/data/non-fatal/home.
10. Zatzick D, et al. A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury. Ann Surg 2008;248(3):429–37.
11. Krebs EE, et al. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med 2007;22(10):1453–8.
12. Northwestern University HealthMeasures. Pain intensity. Evanston, IL: Northwestern University, Feinberg School of Medicine; 2020 Jun 4. PROMIS; https://staging.healthmeasures.net/images/PROMIS/manuals/PROMIS_Pain_Intensity_Scoring_Manual.pdf.
13. Northwestern University HealthMeasures. Pain quality. Evanston, IL: Northwestern University, Feinberg School of Medicine; 2018 Feb 15. PROMIS; http://www.healthmeasures.net/images/PROMIS/manuals/PROMIS_Pain_Quality_Scoring_Manual.pdf.
14. Buysse DJ, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28(2):193–213.
15. Northwestern University HealthMeasures. Sleep disturbance. Evanston, IL: Northwestern University, Feinberg School of Medicine; 2018 Jul 13. PROMIS; http://www.healthmeasures.net/administrator/components/com_instruments/uploads/PROMIS%20Sleep%20Disturbance%20Scoring%20Manual%20(2).pdf.
16. Julian LJ. Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S467–S472.
17. Northwestern University HealthMeasures. List of adult measures: available PROMIS measures for adults. Evanston, IL: Northwestern University, Feinberg School of Medicine; 2021 May 10. https://www.healthmeasures.net/explore-measurement-systems/promis/intro-to-promis/list-of-adult-measures.
18. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67(6):361–70.
19. Kroenke K, et al. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003;41(11):1284–92.
20. Bryant RA, et al. Acute Stress Disorder Scale: a self-report measure of acute stress disorder. Psychol Assess 2000;12(1):61–8.
21. Blevins CA, et al. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress 2015;28(6):489–98.
22. Prins A, et al. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): development and evaluation within a veteran primary care sample. J Gen Intern Med 2016;31(10):1206–11.
23. PTSD: National Center for PTSD. Understanding PTSD and PTSD treatment. Washington, DC: U.S. Department of Veterans Affairs; 2019 May. https://www.ptsd.va.gov/publications/print/understandingptsd_booklet.pdf.
24. American Psychological Association. Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. Washington, DC; 2017 Feb 24. https://www.apa.org/ptsd-guideline/ptsd.pdf.
25. Sateia MJ, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2017;13(2):307–49.
26. Yaremchuk KL. Evaluation of patients with sleep disorders. In: Yaremchuk KL, Wardrop PA, editors. Sleep medicine. San Diego, CA: Plural Publishing, Inc.; 2010.
27. International Association for the Study of Pain. Terminology. Pain terms and definitions: pain. 1994. https://www.iasp-pain.org/resources/terminology/#pain.
28. World Health Organization. ICD-11 for mortality and morbidity statistics. Geneva, Switzerland; 2022. International Classification of Diseases; https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1404135736.
29. Chou R, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016;17(2):131–57.
30. Dowell D, et al. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;65(1):1–49.
31. Joint Commission. Pain assessment and management standards for ambulatory care. Oakbrook Terrace, IL; 2018 Jun 25. R3 report #14.
32. Wellington B. Soft tissue, peripheral nerve and and brachial plexus injury. In: Clarke S, Santy-Tomlinson J, editors. Orthopaedic and trauma nursing: an evidence-based approach to musculoskeletal care. Chichester, West Sussex, UK: John Wiley and Sons; 2014.
33. El-Tallawy SN, et al. Management of musculoskeletal pain: an update with emphasis on chronic musculoskeletal pain. Pain Ther 2021;10(1):181–209.
34. George MD, et al. Risk of nonunion with nonselective NSAIDs, COX-2 inhibitors, and opioids. J Bone Joint Surg Am 2020;102(14):1230–8.
35. White AE, et al. The effect of nonsteroidal anti-inflammatory drugs and selective COX-2 inhibitors on bone healing. HSS J 2021;17(2):231–4.
36. Vallerand AH, Sanoski CA. Davis's drug guide for nurses. 17th ed. Philadelphia, PA: F.A. Davis Company; 2021.
37. Gulam S, et al. Still too noisy—an audit of sleep quality in trauma and orthopaedic patients. Int Emerg Nurs 2020;49:100812.
38. Yang Y, et al. Prevalence and association of anxiety and depression among orthopaedic trauma inpatients: a retrospective analysis of 1994 cases. J Orthop Surg Res 2020;15(1):587.
39. Shulman BS, et al. Sleep disturbance after fracture is related to emotional well-being rather than functional result. J Orthop Trauma 2015;29(3):e146–e150.
40. Yang H, et al. Evaluation of sleep disorder in orthopedic trauma patients: a retrospective analysis of 1129 cases. J Orthop Surg Res 2021;16(1):344.
41. Gandolfi JV, et al. The effects of melatonin supplementation on sleep quality and assessment of the serum melatonin in ICU patients: a randomized controlled trial. Crit Care Med 2020;48(12):e1286–e1293.
42. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67(4):674–94.
43. Chua KP, et al. Association between receipt of overlapping opioid and benzodiazepine prescriptions from multiple prescribers and overdose risk. JAMA Netw Open 2021;4(8):e2120353.
44. Burgess HJ, Emens JS. Drugs used in circadian sleep-wake rhythm disturbances. Sleep Med Clin 2020;15(2):301–10.
45. Khaing K, Nair BR. Melatonin for delirium prevention in hospitalized patients: a systematic review and meta-analysis. J Psychiatr Res 2021;133:181–90.
46. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC; 2013.
47. Beleckas CM, et al. Relative prevalence of anxiety and depression in patients with upper extremity conditions. J Hand Surg Am 2018;43(6):571.e1–571.e8.
48. Beleckas CM, et al. Anxiety in the orthopedic patient: using PROMIS to assess mental health. Qual Life Res 2018;27(9):2275–82.
49. Castillo RC, et al. Longitudinal relationships between anxiety, depression, and pain: results from a two-year cohort study of lower extremity trauma patients. Pain 2013;154(12):2860–6.
50. Wong EM, et al. Effectiveness of an educational intervention on levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma. J Adv Nurs 2010;66(5):1120–31.
51. Hearn JH, Cross A. Mindfulness for pain, depression, anxiety, and quality of life in people with spinal cord injury: a systematic review. BMC Neurol 2020;20(1):32.
52. Nilsson U. The anxiety- and pain-reducing effects of music interventions: a systematic review. AORN J 2008;87(4):780–807.
53. Levy HC, et al. A meta-analysis of relapse rates in cognitive-behavioral therapy for anxiety disorders. J Anxiety Disord 2021;81:102407.
54. Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry 2008;69(4):621–32.
55. Carpenter JK, et al. Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo-controlled trials. Depress Anxiety 2018;35(6):502–14.
56. National Institute for Health and Care Excellence (NICE). Generalised anxiety disorder and panic disorder in adults: management. CG113 ed. London, U.K.; 2019. Guidelines; https://www.ncbi.nlm.nih.gov/pubmed/31961629.
57. Bandelow B, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int J Psychiatry Clin Pract 2012;16(2):77–84.
58. Archer KR, et al. Clinical significance of pain at hospital discharge following traumatic orthopedic injury: general health, depression, and PTSD outcomes at 1 year. Clin J Pain 2016;32(3):196–202.
59. Kendrick D, et al. Early risk factors for depression, anxiety and post-traumatic distress after hospital admission for unintentional injury: multicentre cohort study. J Psychosom Res 2018;112:15–24.
60. Richmond TS, et al. Contributors to postinjury mental health in urban Black men with serious injuries. JAMA Surg 2019;154(9):836–43.
61. Gabriel FC, et al. Pharmacological treatment of depression: a systematic review comparing clinical practice guideline recommendations. PLoS One 2020;15(4):e0231700.
62. Cheng YS, et al. Therapeutic benefits of pharmacologic and nonpharmacologic treatments for depressive symptoms after traumatic brain injury: a systematic review and network meta-analysis. J Psychiatry Neurosci 2021;46(1):E196–E207.
63. Sander LB, et al. Effectiveness of a guided web-based self-help intervention to prevent depression in patients with persistent back pain: the PROD-BP randomized clinical trial. JAMA Psychiatry 2020;77(10):1001–11.
64. PTSD: National Center for PTSD. PTSD screening and referral: for health care providers. Washington, DC: U.S. Department of Veterans Affairs; 2021. https://www.ptsd.va.gov/professional/treat/care/screening_referral.asp.
Keywords:

acute stress disorder; anxiety; depression; mental health; orthopedic trauma; pain; posttraumatic stress disorder; sleep disturbances; symptom management; traumatic orthopedic injury

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