CORR Insights®: Patient-reported Anxiety Scores Are Associated With Lower Physical Function in Patients Experiencing Orthopaedic Trauma

Where Are We Now?

As orthopaedic surgeons, we have a keen interest in the complex machinery that makes up the musculoskeletal system: the laws of physics that govern locomotion, the biological interactions between man-made implants and their in vivo environment, and the molecular mechanisms and signaling pathways that regulate bony and tendinous healing. As musculoskeletal specialists, we strive to foster a deep understanding of these intricate systems because they allow us to provide the best care for our patients. However, as illustrated by the current study by Myhre et al. [5], an understanding of the mechanics of the human body without a comparable understanding of the human mind is insufficient to treat musculoskeletal illness effectively.

In their well-done retrospective study [5], the authors sought correlations between early postoperative anxiety scores and late recovery measures of physical function and found that symptoms of anxiety were strongly associated with symptom intensity among patients with lower extremity fractures. This study affirms the strong interaction between orthopaedic pathology (such as femur fracture) and the human mind (such as mood and coping) [2].

Although our understanding of the machinery of the human body has improved considerably over the past couple of decades, the mechanics of the human mind have mostly remained a black box. We were aware of the direct relationship between mental health and patient-reported limitations, yet the current study by Myhre at al. [5] takes this knowledge one step further by demonstrating that this relationship remains stable over time. At this point, from studies like the one in this month’s Clinical Orthopaedics and Related Research®, we know enough to say that it’s the responsibility of every orthopaedic surgeon to screen for, recognize, and help the patient address symptoms of anxiety and depression that may be present, because we know these symptoms strongly influence the results we can expect from any interventions we perform on a patient’s musculoskeletal system.

Where Do We Need to Go?

Key unanswered questions pertain mainly to implementation; for example, what can we learn from this line of evidence that we can implement in a busy orthopaedic practice? And how can we surgeons—as algorithmic thinkers—learn to mesh our technical skills with the soft skills required to recognize and address psychosocial components of illness to be the most effective clinician?

Better care for patients with symptoms of depression and anxiety starts with improved recognition by the orthopaedic surgeon, which can be achieved through raising surgeon awareness of the importance of mental health through scientific research (such as the current study by Myhre et al. [5]). Another study published in CORR® found that surgeon emotion, as measured with facial recognition software, correlates with patient mood and mindset, suggesting that clinicians register the patient’s emotions, regardless of whether those surgeons are consciously aware of them [6]. A study conducted by my research group found that surgeons who are exposed to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms were more likely to detect such language in (simulated) patient interactions, suggesting that training and practice are effective in increasing attunement to the psychosocial aspects of illness [1]. One important rule of thumb for recognizing decreased mental health is that it can be associated with symptom intensity that is disproportionate to the pathologic findings. If patient-reported limitations do not seem to correspond with the findings on physical examination or imaging, a diagnosis of decreased mental health should be considered and further explored before additional imaging is ordered [4].

To take care of orthopaedic patients with decreased mental health, we need to establish referral patterns with psychologists, psychiatrists, or advanced practice professionals to direct patients to the care they need. When patients present to orthopaedic surgeons with peripheral arterial disease, we refer them to a vascular surgeon before performing orthopaedic surgery. When patients have uncontrolled diabetes, we refer them to their primary care doctors or internists before proceeding with operative treatment. Likewise, depression should be regarded as a comorbid illness (read: a separate entity) that should be treated in concert with musculoskeletal symptoms and should not be regarded as a byproduct of the disease [3] or left untreated as we proceed toward some intervention on the musculoskeletal system, which may not go as well as it would if the depression had been treated before the orthopaedic operation.

Treatment of comorbid symptoms of depression and anxiety should be seen as one important facet of a comprehensive approach to treating musculoskeletal illness that considers all factors contributing to symptom severity.

How Do We Get There?

The first step toward raising awareness about the importance of mental health, decreasing its stigma, and better directing care for patients with low mood is to change the narrative: We, as a profession, need to stop thinking about addressing psychosocial factors as soft skills that are less important than our technical skills in the operating room or our knowledge about illnesses. Depression and anxiety are measurable and have associations with patient-reported physical function that are both statistically robust and clinically important in terms of their effect sizes; ignoring this aspect of the illness will inevitably lead to poorer patient-reported outcomes, lower patient satisfaction, and unnecessary tests.

Beyond surgeons’ personal responsibility to recognize and address decreased mental health, one potential avenue to implement these changes on a system level might be to tie reimbursement to recognizing and addressing mental health (such as through a separate Current Procedural Terminology code or modifier), because this could prevent patients with poor mental health from losing access to musculoskeletal care.

As orthopaedic surgeons, a diagnosis of depression or anxiety disorder and its treatment may be beyond the scope of our practice, but preoperative risk management is certainly our task as surgeons. As musculoskeletal specialists, it is our duty to recognize that depression and anxiety are important determinants of patient-reported physical function and to help patients with identifiable emotional distress receive the psychologic care and support that would allow them to get the best possible results from the surgical procedures we perform.