Psychosocial Intervention and Rehabilitation Utilization Together Improve Pain and Function After Traumatic Orthopaedic Injuries: A Secondary Analysis of a Randomized Controlled Trial.

backgroundPoor psychological response to injury is associated with the development of chronic pain after traumatic orthopaedic injury, but psychological response to injury is modifiable with appropriate identification and intervention. Rehabilitation (physiotherapy, occupational therapy) is often a critical part of pain and functional recovery. It is unknown whether rehabilitation utilization improves psychological response to injury and whether the combination of rehabilitation and a psychosocial intervention may be most effective at improving pain and functional outcomes for patients after orthopaedic trauma. QUESTION/PURPOSE: In a secondary analysis of a randomized trial, we asked: Do postintervention pain, function, pain catastrophizing, and pain-related anxiety differ between patients who received a psychosocial intervention (Toolkit for Optimal Recovery [TOR]) and/or rehabilitation and those who received a standard education control (minimally enhanced usual care [MEUC]) and no rehabilitation after a traumatic orthopaedic injury?

methodsThe earlier randomized controlled trial (RCT) whose data we are analyzing retrospectively here focused on assessing the multisite feasibility of delivering a psychosocial intervention (TOR) after traumatic orthopaedic injuries in patients with high pain catastrophizing or pain-related anxiety. That trial randomized patients to TOR versus MEUC. TOR teaches patients coping skills to navigate emotional challenges during injury recovery, and MEUC consists of a booklet containing information on injury recovery. In the parent RCT, rehabilitation was not randomized and was at the discretion of the treating surgeon. Surveys and rehabilitation utilization (physiotherapy or occupational therapy; yes/no) were completed at baseline (1 to 2 months after injury) and postintervention. The parent RCT obtained complete data sets on 92% (76 of 83) and 95% (93 of 98) of patients in those groups, respectively, at the postintervention time point (4 to 6 weeks after baseline). The present analysis therefore included a total of 181 adults (65% [119] women, mean ± SD age 44 ± 17 years). Groups did not differ in terms of baseline characteristics including sex, gender, age, pain, function, pain catastrophizing, or pain-related anxiety. We created a four-category variable (TOR with rehabilitation, TOR without rehabilitation, MEUC with rehabilitation, and MEUC without rehabilitation). Controlling for baseline levels, analysis of covariance via generalized linear model procedures tested the role of this categorical variable on postintervention pain, function, pain catastrophizing, and pain-related anxiety. To enhance clinical relevance, we evaluated the achievement of minimum clinically important differences (MCIDs) for each outcome by comparing pre-post changes in mean scores between the intervention groups and the reference group (MEUC without rehabilitation).

resultsBoth TOR with and without rehabilitation groups had lower postintervention pain at rest scores compared with the reference MEUC without rehabilitation group (the difference versus reference was 1.4 for TOR with rehabilitation and 1.6 for TOR without rehabilitation, both of which were greater than the MCID of 1.3), whereas the MEUC with rehabilitation group did not show a clinically important difference compared with the reference group. Only the TOR with rehabilitation group had lower postintervention functional disability scores compared with the reference group (the difference versus reference was 10.9, which was greater than the MCID of 7). We observed no clinically important difference in postintervention function between the TOR without rehabilitation group and the reference group or between the MEUC with rehabilitation group and the reference group. Only the TOR groups had lower postintervention pain catastrophizing scores (the difference versus reference was 6.2 for TOR without rehabilitation and 9.1 for TOR with rehabilitation, both of which were greater than the MCID of 4.5) and lower postintervention pain-related anxiety scores (the difference versus reference was 24.0 for TOR without rehabilitation and 20.9 for TOR with rehabilitation, both of which were greater than the MCID, defined as > 30% change between time points).

conclusionThe combination of TOR and rehabilitation utilization resulted in short-term improvements in physical function after traumatic orthopaedic injury. Participants who received TOR experienced clinically meaningful short-term improvements in pain, pain catastrophizing, and pain anxiety. These data may support the inclusion of screening for psychological response to injury within routine clinical practice. For patients with a maladaptive psychological response to their traumatic orthopaedic injury, these data may support referrals to rehabilitation and mental health providers as part of a comprehensive injury management plan. LEVEL OF EVIDENCE: Level III, therapeutic study.