Section 3: Management of Pain and Psychosocial Consequences

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There are a number of factors that affect a patient's recovery after an extremity injury. In particular, chronic pain, depression, anxiety and posttraumatic stress disorder (PTSD) have significant impact on return to preinjury function and work.1,2 Studies report chronic pain in up to 72% of trauma patients a year after injury.3–5 Patients who are in significant pain at the time of discharge from the hospital are likely to experience pain 1 year later.4,6,7 In some cases, patients continue to experience pain as long as 7 years after the injury,5 and consequently, return to work is challenging.
In addition to chronic pain, psychological distress (ie, depression, anxiety, and PTSD) is prevalent after traumatic injury with roughly 15%–20% reporting severe levels of distress.8,9 The relationships between pain, psychological distress, and functional recovery are complex. Data from the Lower Extremity Assessment Project demonstrate that early in recovery, the level of pain drives the level of psychological distress; but as recovery continues, the level of psychological distress—specifically anxiety—influences the level of pain.10,11 Other studies have supported these findings by demonstrating an etiological link between early pain and the onset of depression and PTSD. Research has also shown that persistence of pain over time exacerbates these conditions, which in turn negatively impacts recovery and even response to pain management.10
It is important to effectively manage early levels of pain and psychological distress, as even relatively low levels can be detrimental to long-term outcomes. METRC is conducting 2 prospective multicenter trials that will help define best practices in the management of these important sequelae of orthopedic trauma.
The first trial tests the use of a novel perioperative analgesic approach to pain management. Opioid analgesics have had a prominent role in pain management for acute extremity injury.12 The increasing concern of the adverse effects of opioid analgesics has led to an interest in using multimodal perioperative analgesia.13,14 This approach seeks to control pain by taking advantage of synergistic effects of different classes of analgesics, thus reducing the doses of individual drugs and leading to a lower incidence of adverse effects from any individual medication. The Improving Pain Management and Long-Term Outcomes After High Energy Orthopedic Trauma (PAIN) study is a 3 arm randomized controlled trial which tests whether adjunctive analgesic therapy during the preoperative and perioperative period can improve overall pain control and pain-related outcomes without increasing analgesic related side effects.
The second trial tests a new care model which takes a chronic disease management approach to treating the psychosocial sequelae of traumatic extremity injury. To assist in the prevention and management of secondary health conditions, there is a growing body of evidence that the use of 2 complementary models of care—the Collaborative Care and Chronic Care models—15,16can be effective in managing complex medical conditions. These innovative models emphasize the need for patients to assume greater responsibility for their recovery and stress the importance of increasing patient self-efficacy to meet these demands.
The Trauma Collaborative Care Study (TCCS) will provide data on the feasibility of incorporating a collaborative care model in a trauma setting and examine whether this class of interventions can improve long-term outcomes after orthopedic trauma. The centerpiece of the TCC program is the Trauma Survivors Network (TSN) (, developed in collaboration with the American Trauma Society, with the goal of connecting trauma survivors with one another and increasing their self-efficacy, support network, and self-management skills.17 The TCC program also uses TSN coordinators to conduct individualized recovery assessments, provide feedback to the patient and provider, who can use these data to develop treatment recommendations and referral to TSN and community resources.

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