Jochimsen Kate N, Hooker Julia E, Szapary Claire L, Bakhshaie Jafar, Vranceanu Ana-Maria
Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
Harvard Medical School, Department of Psychiatry, Boston, MA, USA.
Clin Orthop Relat Res. 2025 Mar 4;483(8):1514-1524. doi: 10.1097/CORR.0000000000003433.
Poor 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?
The 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).
Both 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).
The 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 III, therapeutic study.
对损伤的不良心理反应与创伤性骨科损伤后慢性疼痛的发生有关，但对损伤的心理反应可通过适当识别和干预来改善。康复治疗（物理治疗、职业治疗）通常是疼痛和功能恢复的关键部分。目前尚不清楚康复治疗的使用是否能改善对损伤的心理反应，以及康复治疗与心理社会干预相结合是否对改善骨科创伤后患者的疼痛和功能结局最为有效。
问题/目的：在一项随机试验的二次分析中，我们提出：在创伤性骨科损伤后，接受心理社会干预（最佳恢复工具包[TOR]）和/或康复治疗的患者与接受标准教育对照（最低限度强化常规护理[MEUC]）且未接受康复治疗的患者相比，干预后的疼痛、功能、疼痛灾难化和与疼痛相关的焦虑是否存在差异？
我们在此回顾性分析数据的早期随机对照试验（RCT）重点评估了在疼痛灾难化程度高或与疼痛相关焦虑的患者中，创伤性骨科损伤后提供心理社会干预（TOR）的多中心可行性。该试验将患者随机分为TOR组和MEUC组。TOR教授患者应对技能，以应对损伤恢复期间的情绪挑战，MEUC包括一本包含损伤恢复信息的手册。在原RCT中，康复治疗未随机分配，由主治外科医生自行决定。在基线（损伤后1至2个月）和干预后完成调查及康复治疗使用情况（物理治疗或职业治疗；是/否）。原RCT在干预后时间点（基线后4至6周）分别获得了这些组中92%（83例中的76例）和95%（98例中的93例）患者的完整数据集。因此，本分析共纳入181名成年人（65%[119名]女性，平均±标准差年龄44±17岁）。各组在基线特征方面无差异，包括性别、年龄、疼痛、功能、疼痛灾难化或与疼痛相关的焦虑。我们创建了一个四类变量（接受康复治疗的TOR组、未接受康复治疗的TOR组、接受康复治疗的MEUC组和未接受康复治疗的MEUC组）。通过广义线性模型程序进行协方差分析，在控制基线水平的情况下，测试该分类变量对干预后疼痛、功能、疼痛灾难化和与疼痛相关焦虑的作用。为提高临床相关性，我们通过比较干预组与参考组（未接受康复治疗的MEUC组）之间平均得分的前后变化，评估了每个结局的最小临床重要差异（MCID）的达成情况。
与未接受康复治疗的参考MEUC组相比，接受康复治疗的TOR组和未接受康复治疗的TOR组干预后的静息疼痛评分均较低（接受康复治疗的TOR组与参考组的差异为1.4，未接受康复治疗的TOR组与参考组的差异为1.6，两者均大于MCID的1.3），而接受康复治疗的MEUC组与参考组相比未显示出临床重要差异。只有接受康复治疗的TOR组与参考组相比干预后的功能残疾评分较低（与参考组的差异为10.9，大于MCID的7）。我们观察到未接受康复治疗的TOR组与参考组之间或接受康复治疗的MEUC组与参考组之间干预后的功能无临床重要差异。只有TOR组干预后的疼痛灾难化评分较低（未接受康复治疗的TOR组与参考组的差异为6.2，接受康复治疗的TOR组与参考组的差异为9.1，两者均大于MCID的4.5），且干预后的与疼痛相关的焦虑评分较低（未接受康复治疗的TOR组与参考组的差异为24.0，接受康复治疗的TOR组与参考组的差异为20.9，两者均大于MCID，定义为时间点之间变化>30%）。
TOR与康复治疗的结合导致创伤性骨科损伤后短期身体功能改善。接受TOR的参与者在疼痛、疼痛灾难化和疼痛焦虑方面经历了具有临床意义的短期改善。这些数据可能支持在常规临床实践中纳入对损伤心理反应的筛查。对于对创伤性骨科损伤有适应不良心理反应的患者，这些数据可能支持将其转介给康复治疗和心理健康服务提供者，作为综合损伤管理计划的一部分。
III级，治疗性研究。
