CORR Insights®: Adverse Childhood Experiences Are Not Associated With Patient-reported Outcome Measures in Patients With Musculoskeletal Illness

Where Are We Now?

In their study, Ottenhoff and colleagues [10] set out to determine whether there is a correlation between adverse childhood experiences (ACEs) and patient-reported outcome measures (PROMs) among patients seeking care in an outpatient upper-extremity orthopaedic practice. The authors did not find a reliable association between ACEs and acute pain, or between ACEs and patient-reported physical functioning in a sample of “typical patients seen in outpatient (orthopaedic) offices with common diseases” [10].

By contrast, previous studies have shown an association between reports of ACEs and health problems during adult life [5-8]. One meta-analysis found that a reported history of childhood abuse or neglect is a risk factor for adult-onset chronic pain, and that these events can be major barriers to recovery [5]. That study documented a dose-response gradient, providing support for a conclusion that ACEs are causative for adult chronic pain. Indeed, people with chronic pain were more likely to seek health care for that pain if they reported ACEs—thereby providing a rare glimpse of the differences between individuals with pain who seek health care and those who do not. Davis and colleagues [5] used their findings to explain why “chronic pain has been declared the next frontier in child maltreatment research.” Regarding mechanisms by which ACEs lead to adult onset chronic pain, they noted: “Disturbances in emotional, behavioral, physiological, and/or social functioning resulting from adverse childhood experiences represent contributing factors to the experience of chronic pain in adulthood and are likely to act as significant barriers to recovery” [5].

The process of sending drafts back and forth between me and the editors resulted in a redundancy emerging which none of us had noticed previously. I have eliminated that redundancy. The process of sending drafts back and forth also resulted in the numbering for references becoming incorrect, so I have fixed that as well.

Another study identified several risk factors for chronic pain [1] that correlate with ACEs including mental illness, smoking, physical inactivity, and obesity [7], and another found ACEs to be a risk factor for opioid dependence [6]. Additionally, texts from the American Psychological Association [3], the American Academy of Pain Medicine [4], and the American Academy of Orthopaedic Surgeons [2] highlight the topic's relevance to orthopaedics by reviewing scientific findings indicating that ACEs raise the risk of failure for surgery, spinal cord stimulation, and other treatments for pain.

In sum, ACEs indicate a need for a cautious approach in the consideration of surgery and other potentially harmful treatments.

Where Do We Need To Go?

This question has public policy implications—specifically regarding primary and secondary prevention. It also prompts a general science discussion, many aspects of which are documented in the current study. But this journal emphasizes “Clinical” in its title, so the remainder of this discussion will be focused on where we need to go clinically.

Green and colleagues [8] offered a succinct recommendation: “Given the impact of abuse, particularly SA (sexual abuse), on the presentation of chronic pain, queries regarding abuse should become a routine component of the patient interview. Abused patients should be referred to mental health care practitioners as a component of successful pain management if unresolved issues persist.”

The findings from the current study, however, indicate that “routine” consideration of such issues may not be necessary for the early phase of treatment for patients with musculoskeletal problems [10]. It might be appropriate to limit consideration of ACEs to presentations of chronic pain (and perhaps other presentations for which medical findings are nonexplanatory), and patients for whom potentially harmful elective treatments are being considered. That possibility would be consistent with published indications that it is acceptable to refrain from referring for a psychological evaluation until a presentation of pain has lasted for 3 months, or until potentially harmful treatments are being considered [2, 4].

Perhaps a simple 3-month rule is adequate. However, it seems arbitrary to wait 3 months to consider ACEs, particularly if medical findings do not provide an explanation for the presentation. We need an understanding of when ACEs should be investigated in an individual case—an understanding that is not based on an arbitrary 3-month guideline.

Ottenhoff and colleagues [10] note that their findings may not be generalizable, considering that participants were mostly white and employed with 4 years of college; they correctly pointed out that more research is needed in more-vulnerable populations. A recent study [9] supports that recommendation, in that ACEs were correlated with being black, Hispanic, multiracial, unemployed, homosexual, bisexual, not completing high school, and reporting an annual income of less than USD 15,000. It is possible that such demographic variables can be used to help determine whether ACEs should be considered for each patient. But there may not be a need to consider ACEs if we can instead more-directly address the links between ACEs and clinical presentations.

There is also a need for studying different methods of assessing ACEs. That need is actually demonstrated by the fact that Ottenhoff and colleagues used a method for evaluating ACEs that is different from the method used in a larger scale study [9].

Finally, it must be noted that consideration of ACEs is clinically meaningless if it does not lead to better outcomes. For example, if we can more directly address the links between ACEs and the current clinical presentation, which may include disturbances in emotional, behavioral, physiological, and/or social functioning resulting from ACEs [5], as well as mental illness, smoking, physical inactivity, and obesity [7], then there might not be any added value from also asking about ACEs.

How Do We Get There?

Determining whether a focus on ACEs can improve outcomes is of primary importance. Indeed, clinicians should perform prospective studies that can determine whether the consideration of ACEs, for adult patients, leads to better outcomes. Ideally, this would involve randomizing research participants into clinical services that do and do not involve consideration of ACEs (a randomization that would be easy to accomplish in almost any clinical setting).

If we find better outcomes, then the data from such projects could also be analyzed in a fashion that might provide guidance for when ACEs should be considered. Potentially relevant considerations include the duration of the clinical presentation, whether medical findings are explanatory, and the demographic issues that have a strong association with ACEs. Such analysis might facilitate a more-personalized consideration of assessing ACEs, rather than a generic 3-month guideline.

Subsequent research could then compare different methods for assessing ACEs, and that type of study could help us determine which methods demonstrate the strongest correlations with relevant clinical presentations (such as medically unexplainable presentations), which are most accurate for identifying patients who benefit from being referred for psychological health care, which are most accurate in predicting treatment outcomes, etc.

This research could also address whether it is necessary to assess ACEs, rather than more-directly assessing apparent links between ACEs and adult presentations. Such a study could randomize patients between services that consider ACEs specifically, versus services that consider issues that we suspect link ACEs to adult health (without considering ACEs). While financially feasible, this type of study has not been performed because the world has not paid sufficient attention to this issue historically.