CORR Insights®: Is Pain in the Uninjured Leg Associated With Unhelpful Thoughts and Distress Regarding Symptoms During Recovery From Lower Extremity Injury?

Where Are We Now?

“I’ve been overcompensating since my injury, and my other leg is hurting now.”

This expression may appear harmless, and all of us have heard something like it from our patients, but in this issue of Clinical Orthopaedics and Related Research®, Romere et al. [9] caution us that this thought process represents an indicator of unhelpful thinking and a negative mindset during trauma recovery.

Trauma is the leading cause of death and disability in the United States for patients younger than 45 years of age [11]. Lower extremity injuries affect mobility and activities of daily living and can cause long-lasting disability and loss of income during the recovery period [3, 5]. Although injury severity has long been thought of as the main predictor of outcome, recent evidence has elucidated psychological and social factors as major elements that influence the recovery course [11].

Romere et al. [9] performed a prospective study of 139 patients with any traumatic lower extremity injury who presented for clinic follow-up. The authors performed a cross-sectional survey to measure pain intensity of the uninjured leg, pain intensity of the injured leg, lower extremity–specific magnitude of capability, symptoms of depression, symptoms of health anxiety, catastrophic thinking, and accommodation of pain. They found that greater pain intensity in the uninjured leg was associated with unhelpful thinking. Based on these results, surgeons should consider counseling patients who report compensating pain of the uninjured leg toward healthier coping strategies during the recovery period. The authors suggest follow-up statements such as, “We hear this a lot, it’s not uncommon,” or “it’s a good kind of sore.” I usually proceed by acknowledging that the patient is having a difficult time, then reassure them about the recovery process. This serves to demonstrate empathy and establish rapport, while providing an opportunity to build long-term trust with the patient.

Where Do We Need To Go?

Health outcomes are the result of a complex interplay of biological, psychological, and social factors. Today, healthcare requires a complete assessment and treatment of all of these components [13]. Mental health and social determinants of health not only increase individuals’ risk for experiencing trauma, they impact their access to care and recovery resources following that trauma [2, 7]. An unfortunate event such as trauma, however, can also be an opportunity to intervene. In the newest edition of best practices guidelines, the American College of Surgeons recommend screening for mental health disorders and substance use among patients who have experienced trauma [1].

There is a growing body of evidence that supports the implementation of a comprehensive recovery program for patients who have been injured. Such programs have been shown to be associated with reduced rates of post-traumatic stress disorder, reduced rates of unplanned representation to the emergency room and hospital admission, improved patient satisfaction, and improved compliance to medical treatment [10, 11, 14]. Given how prominent musculoskeletal injury is in patients who have experienced severe trauma, orthopaedic surgeons play a vital part in the recovery program's success.

Romere et al. [9] highlight that caring for patients who have experienced trauma requires attention beyond the physical wounds. They illustrate examples of verbal and behavioral cues that orthopaedic surgeons can detect when an injured patient experiences unhelpful thoughts. These examples represent an opportunity to identify patients who are at risk for poor coping and would benefit from more coaching and recovery support. To become salient for orthopaedic surgeons, future studies should demonstrate the benefits of mental health interventions during trauma recovery and the positive downstream effects in patient physical and functional outcomes. This could be accomplished with clinical metrics such as strength, mobility, or patient-reported outcome measures.

How Do We Get There?

Orthopaedic surgeons and trauma centers are skilled in the acute management of musculoskeletal injuries. However, most trauma centers do not have formal programs or resources devoted to improving the mental and social health of patients who have experienced trauma. Common obstacles include the lack of hospital or administrative support, and hospitals are not incentivized to provide these services [11]. Patient benefits that may be obvious to surgeons and providers may not be clear to hospital systems. Further evidence that demonstrates improved outcomes for patients and subsequent hospital benefits from lower recidivism, perioperative complications, and cost will lend more support for such programs.

Naturally, a team approach would be best when implementing a comprehensive multidisciplinary recovery program for patients with severe musculoskeletal injuries [6]. An example trauma-recovery model may include a mental health counselor, a social worker, and a patient peer supporter [10, 11]. A standard 15-minute postoperative appointment may already be rushed, even when strictly focused on the musculoskeletal injury, but if orthopaedic surgeons are trained to identify patients who display signs of emotional distress, they can facilitate care to the appropriate providers. Several approaches have been suggested that do not add strain to already busy practices. The Traumatic Injuries Distress Scale is an example survey that can accomplish this task in less than three minutes and does not require additional staff to administer [4, 8]. Health systems should be equipped and work in conjunction across different specialties in a concerted effort to improve trauma recovery.

Romere et al. [9] gave us a glimpse into one such possibility for improving recovery and providing mental health support during the rehabilitation process. Additional studies on trauma recovery are needed to identify mental health and social support interventions that will lead to improved outcomes. Details on how to implement an effective trauma recovery model would benefit patients, providers, and trauma systems.