According to published literature, Posttraumatic Stress Disorder (PTSD) occurs in 20% to 51% of patients with musculoskeletal injury. In one study, fully 57% of patients involved in motor vehicle accidents and 65% of pedestrians hit by a motor vehicle met the criteria for PTSD.1 And when present, PTSD can considerably worsen orthopedic outcomes.
Posttraumatic Stress Disorder (PTSD), a condition caused by witnessing or experiencing a traumatic event, isn’t just for those in the military…it is also “alive and well” among civilians who experience orthopedic trauma. But because orthopedic surgeons aren’t trained to be on the lookout for the symptoms, they may miss the warning signs. And this, says a recently published article, can result in less than optimal clinical results.
Dr. Daniel Aaron, an orthopedic surgeon with Rhode Island Hospital in Providence, is the lead author of this review article, which was recently published in the Journal of the American Academy of Orthopaedic Surgeons. He states, “Posttraumatic Stress Disorder has been consistently noted in the literature as being a distinct entity, i.e., one that is a different behavioral phenotype that is separate from phobic anxiety or clinical depression. It involves three symptom clusters, the first being a reexperiencing of the traumatic event in the form of nightmares, flashbacks, and unwanted memories. The second cluster involves avoidance of things that remind the person of the trauma, as well as emotional numbing. With the third cluster we see hyper arousal that manifests itself in irritability, difficulty concentrating, insomnia, and an increased startle response.”
Orthopedists, naturally, are more accustomed to being attuned to physical complaints. But, says Dr. Aaron, it pays to adjust your tuning forks to the patient’s inner pains as well. “Our review, which covered only the subset of patients involved in high-energy trauma, revealed some interesting statistics.”
I was greatly surprised to find that in some studies, there was such a high percentage of civilian orthopedic patients that go on to develop PTSD after a traumatic event…it was around the 50% range.
“This is very detrimental to the patient, who, for example, may be experiencing a depressed mood and can’t quite get him or herself to physical therapy. We also know that when asked to do a self assessment of his treatment progress, someone in this mental state tends to have a skewed view of how things are coming along.”
And for the orthopedic surgeon, all of this means that his or her outcomes could be less than optimal. Dr. Aaron: “For example, let’s take a patient with a femur fracture. Normally, you could expect a return to full functioning within about six months. If that person has PTSD, however, their entire recovery process could be extended by several months. But the bottom line is that at present there are no protocols for dealing with PTSD in those with musculoskeletal injuries…and we are only just beginning to explore the ramifications of this condition on orthopedic patients.”
Highlighting how the three symptom clusters might “show up” in the exam room, Dr. Aaron adds a bit of anecdotal information:
“More than reexperiencing or hyperarousal what my colleagues and I have frequently come across is avoidance. Patients can’t bring themselves to get back in a car or drive on the highway after an accident, for example.”
“Hyperarousal (difficulty concentrating, mood swings, etc.) is more subtle, and can usually be unearthed once the doctor’s suspicions about possible PTSD have been raised. Reexperiencing is easier to assess, as inquiries about nightmares and flashbacks are generally easier for patients to understand than hyperarousal—and reexperiencing is simpler for the doctor to elicit.”
“You can begin by asking general questions about the patient’s mood. Sometimes just doing that is enough because people need/want to talk. And don’t discount the fact that it probably makes patients feel a little less abnormal if their doctor is taking their symptoms and concerns seriously…they are being validated. And in the likely event that you have to recommend a psychiatric evaluation, they could be more apt to agree because they like and trust you.”
Often, it’s not just the patient who needs convincing. Dr. Aaron says,
If anyone has doubts about whether or not PTSD is a ‘real’ diagnosis, just look to biology for proof.
“There are several studies that have found an elevated reactivity in the hypothalamic-pituitary axis and neurotransmitter levels in those who are vulnerable to trauma. A variety of imaging studies have pointed to the amygdala as being the location of conditioned emotional responses…including fear. Actually, in individuals diagnosed with PTSD, amygdaloid activity has been shown to be dysregulated, i.e., this area of the brain lights up when traumatic memories are called up.”
Even genetics is involved, states Dr. Aaron. “One study we referenced was about people in the vicinity of the Twin Towers on 9/11…the researchers found specific genetic profiles that correlate with the risk of developing PTSD. Somewhere down the line we might be able to incorporate this information into risk stratification for this condition.”
Dr. Aaron, who says that there are likely many more psychological manifestations of change in patients’ musculoskeletal functioning than we realize, notes,
“The ultimate goal is to develop techniques that will help us stratify patient risk, something that would allow us to recognize and diagnose PTSD—or the risk of PTSD—at an earlier point in the treatment process. Then the clincher…we need an established set of recommendations as to how to prevent this condition from developing.”
“At present there is speculation that some form of psychotherapy coupled with psychiatric medication can make a difference. A particularly pressing question for orthopedists is, ‘Will the successful treatment of the emotional symptoms of PTSD correlate with improved physical outcomes?’”
“We do know that those who are young, female, poorly educated, have a limited economic situation, and use drugs and alcohol are especially at risk for this condition. In fact, women are twice as likely as men to experience this condition at some point in their lives; there is also some evidence that Hispanic patients may be at increased risk.”
Discussing a possible point of intervention, Dr. Aaron says, “There is some evidence to show that individuals with Acute Stress Disorder (ASD) are more likely to develop PTSD.”
If you are seeing someone within a month of their trauma (a criterion for the diagnosis of ASD) and they are anxious and seem to be demonstrating an increased state of arousal, then that could be a good point to refer someone to a mental health professional.
“There are some studies indicating that certain responses to questions could be predictive of ASD. There certainly could be a role for that sort of screening in the ER. At present, however, it is only being done in a research context.”
Source: Wikimedia Commons and U.S. Navy photo by Photographer’s Mate 2nd Class Jayme PastoricAnother vital determinant of whether or not someone goes on to develop this condition is his or her level of social support. Dr. Aaron: “Socioeconomic factors come into play in that those patients with a reliable and caring support network tend to fare better. It’s likely that those with more money have more flexibility in their schedules to take care of an ailing family member. This raises the question of whether we should enlist those in the patient’s support system to be active participants in their care.”
Sounds complex and delicate…perhaps orthopedic care should be delayed until the PTSD is treated. An adamant Dr. Aaron says, “No. There is a very real interplay between the emotional and physical factors. If we can improve someone’s physical health, then there is a good chance that they will start feeling better psychologically, and vice versa.”
“Overall, ” says Dr. Aaron, “we don’t have a well devised strategy for preventing PTSD. While there is some ‘psychopharmacologic inoculation’ (the administration of psychotropic medication in the acute post injury phase) occurring on an experimental basis, the results of those initiatives are not in yet. As for treatment, the patient may need something called exposure therapy wherein the person reviews the trauma repeatedly with a mental health professional. The goal is to gradually have the memories cause the patient less distress.”
“The best thing we can do now is to pursue the development of a protocol for early recognition and early intervention. If we recognize PTSD or the risk of PTSD not only can we make arrangements for the patient to get behavioral treatment, but we may find that their functional outcome from the musculoskeletal injury will improve in a corresponding fashion. It seems that patients who develop these symptom clusters cannot walk as far and they do not return to work as quickly. So the question is, ‘What good can we do? Can we get them back to work as their emotional symptoms are addressed?’ We need to follow patients over the course of their PTSD treatment and monitor their progress from a psychological standpoint while determining if their physical outcomes are proportional.”
So are Dr. Aaron’s cohorts responding well to this study? “We are finding that our colleagues are receiving this work well, and in fact are saying, ‘I’ve had similar experiences with patients. Thanks for the validation and insights.’ My hope is that we will eventually have a short set of questions for orthopedists to use. We routinely get EKGs and chest X-rays for preop patients; in a similar fashion (based on someone’s past history/psychological profile) we could make getting a psychiatric consult more routine.”
“We have a responsibility to ‘hang in there’ with our patients if we suspect that there is the possibility of emotional sequelae from trauma. Because of our obligation to have the person evaluated and possibly treated by a mental health professional, it may be that we will be involved for a longer period of time with these patients because their physical healing may progress more slowly.”
In essence, you can’t leave them at the OR door.
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1Starr AJ, Smith WR, Frawley WH, et al: Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am 2004;86(6):1115- 1121.
