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Psychological Distress in Patients with Orthopaedic Trauma Injuries

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Material Information

Title:
Psychological Distress in Patients with Orthopaedic Trauma Injuries
Physical Description:
1 online resource (70 p.)
Language:
english
Creator:
Barnes, Robert T
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Rehabilitation Science
Committee Chair:
Horodyski, Marybeth
Committee Members:
Vincent, Heather K
Vincent, Kevin R
Conrad, Bryan
Sadasivan, Kalia Kumar

Subjects

Subjects / Keywords:
anxiety -- depression -- orthopaedic-trauma -- psychology
Rehabilitation Science -- Dissertations, Academic -- UF
Genre:
Rehabilitation Science thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
The aim of this investigation was to examine theprevalence, magnitude and contributors of psychological distress in patientssuffering from orthopaedic trauma injuries. The absence of research on the topic is unexpected considering themultiple experts today’s Level-I trauma facilities have at their disposal, andthe millions of trauma injuries occurring annually.  As such, 50 consecutive participants who metinclusion criteria and had incurred orthopaedic trauma injuries wereadministered the state-version of the State-Trait Anxiety Inventory (STAI) andthe Beck Depression Inventory Second Edition (BDI-II) following their hospitaldischarge at a scheduled in-clinic trauma appointment.  Patients with severe orthopaedic traumainjuries were asked to participate.  “Severe” was defined as patients whosustained multiple fractures, received more than one surgical procedure, andstayed multiple days in the hospital while rehabilitating their orthopaedictrauma injuries.   Results indicated that the prevalence and magnitude ofpsychological distress in the study cohort far exceeded norms established inthe general population.  Of note, eachparticipant experienced elevated levels of anxiety (STAI = 63.2 ± 7.1),while 92% of the study cohort suffered from moderate or severe depression(BDI-II = 29.8± 8.6).  In all, 94% of patientsself-reported that they believed psychological distress was “caused” or “exacerbated”by their orthopaedic trauma injury.  Dueto the prevalence and magnitude of psychological distress in the study cohort,no significant differences in anxiety or depression scores were found for thosewith a prior history of psychological distress compared to participants without a history.  Furthermore, no correlation was evidencedbetween Injury Severity Scores (ISS) and anxiety or depression.  Unexpectedly, participants receivingtreatment for their psychological distress did not differ from participants whodid not.  Finally, significant negativecorrelations were evidenced between social support and anxiety and socialsupport and depression.  Participantswith less social support as measured by the Multidimensional Scale of PerceivedSocial Support (MSPSS) experienced greater anxiety and depression scores.  Considering the prevalence and magnitude ofpsychological distress in the study cohort, traumatologists should consideradopting an interdisciplinary team to help restore optimal physical recovery,to assist in ameliorating psychological distress, and to provide empathetic andcomplete care.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Robert T Barnes.
Thesis:
Thesis (Ph.D.)--University of Florida, 2013.
Local:
Adviser: Horodyski, Marybeth.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2015-08-31

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2013
System ID:
UFE0045365:00001

MISSING IMAGE

Material Information

Title:
Psychological Distress in Patients with Orthopaedic Trauma Injuries
Physical Description:
1 online resource (70 p.)
Language:
english
Creator:
Barnes, Robert T
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Rehabilitation Science
Committee Chair:
Horodyski, Marybeth
Committee Members:
Vincent, Heather K
Vincent, Kevin R
Conrad, Bryan
Sadasivan, Kalia Kumar

Subjects

Subjects / Keywords:
anxiety -- depression -- orthopaedic-trauma -- psychology
Rehabilitation Science -- Dissertations, Academic -- UF
Genre:
Rehabilitation Science thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
The aim of this investigation was to examine theprevalence, magnitude and contributors of psychological distress in patientssuffering from orthopaedic trauma injuries. The absence of research on the topic is unexpected considering themultiple experts today’s Level-I trauma facilities have at their disposal, andthe millions of trauma injuries occurring annually.  As such, 50 consecutive participants who metinclusion criteria and had incurred orthopaedic trauma injuries wereadministered the state-version of the State-Trait Anxiety Inventory (STAI) andthe Beck Depression Inventory Second Edition (BDI-II) following their hospitaldischarge at a scheduled in-clinic trauma appointment.  Patients with severe orthopaedic traumainjuries were asked to participate.  “Severe” was defined as patients whosustained multiple fractures, received more than one surgical procedure, andstayed multiple days in the hospital while rehabilitating their orthopaedictrauma injuries.   Results indicated that the prevalence and magnitude ofpsychological distress in the study cohort far exceeded norms established inthe general population.  Of note, eachparticipant experienced elevated levels of anxiety (STAI = 63.2 ± 7.1),while 92% of the study cohort suffered from moderate or severe depression(BDI-II = 29.8± 8.6).  In all, 94% of patientsself-reported that they believed psychological distress was “caused” or “exacerbated”by their orthopaedic trauma injury.  Dueto the prevalence and magnitude of psychological distress in the study cohort,no significant differences in anxiety or depression scores were found for thosewith a prior history of psychological distress compared to participants without a history.  Furthermore, no correlation was evidencedbetween Injury Severity Scores (ISS) and anxiety or depression.  Unexpectedly, participants receivingtreatment for their psychological distress did not differ from participants whodid not.  Finally, significant negativecorrelations were evidenced between social support and anxiety and socialsupport and depression.  Participantswith less social support as measured by the Multidimensional Scale of PerceivedSocial Support (MSPSS) experienced greater anxiety and depression scores.  Considering the prevalence and magnitude ofpsychological distress in the study cohort, traumatologists should consideradopting an interdisciplinary team to help restore optimal physical recovery,to assist in ameliorating psychological distress, and to provide empathetic andcomplete care.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Robert T Barnes.
Thesis:
Thesis (Ph.D.)--University of Florida, 2013.
Local:
Adviser: Horodyski, Marybeth.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2015-08-31

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2013
System ID:
UFE0045365:00001


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1 PSYCHOLOGICAL DISTRESS IN PATIENTS WITH ORTHOPAEDIC TRAUMA INJURIES By ROBERT TARKINGTON BARNES A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2013

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2 2013 Robert Tarkington Barnes

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3 To Leslie, Mr. Deuce, and above all, Miss Juan. She would certainly not stand, or sit, for anything less. Lovingly, each of you sprang into my life I knelt down and put my arms around them. I knew that if it hadn't been for their loyalty and unselfish courage I would have probably been killed by the slashing claws of the devil cat. 'I don't know how I'll ever pay you back for what you've done,' I said, 'but I'll never forget it. Wilson Rawls, Where the Red Fern Grows

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4 ACKNOWLEDGMENTS I doubt Dante was referring to a doctoral program when penning his dissertation. Yet midway through this journey I also found myself within a forest dark, for the straightforward pathway had been lost. Like Dante guidance and salvation came from my two legged and four legged companions. My wife Leslie is my inspiration, best friend, true love and constant reminder of everything t hat is good in life. My dogs, Miss Juan and Mr. Deuce, are love personified and never cease to provide friendship, loyalty and a reminder that the small things in life like chasing squirrels can be just as meaningful as writing grants or analyzing data. My parents Dave and Sherry Barnes, sister Alison and brother Zak have always supported my academic and athletic goals prompting me to realize that despite the pitchback, I hit the adoptive lottery. Coupled with the support of my grandparents, I have been truly blessed and supported while completing this lengthy and arduous project. I will forever be indebt to Dr. MaryBeth Horodyski for her amazing abilities as an advisor. Like a great coach, Dr. Horodyski is someone you want to do your best for not becaus e you must, but because you want to make her proud. Her abilities as an educator and mentor are unmatched. She is the model template for practicing interdisciplinary science, leading by example, and helping graduate students find and pursue their passion Dr. Kalia Sadasivan has also been an invaluable mentor and will undoubtedly be a lifelong friend. He has given me a worldclass education in orthopaedics, humanism and most importantly, life. He is an exceptional surgeon, but an even more amazing human being. I would like to thank Dr. Heather Vincent, Dr. Kevin Vincent and Dr. Bryan Conrad for welcoming me into the UF Sports Performance Center, UF Running

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5 Medicine Clinic and UF Biomechanics and Motion Analysis Lab. Your gifts of providing guidance on a day to day basis and willingness to serve on an interdisciplinary committee allowed this project to be completed. I am also thankful for Dr. Linda Kline my original inspiration for attending graduate school and constant supporter. Luke Reid, Mac Whitl ey, Marna Whitley, James Hocking, Greg Barnes, Sue Greishaw, Dr. Jeremy Delcambre, Dr. Gretchen Delcambre, Dr. Derek Mann, and Dr. Melanie Mousseau provided the friendship, love and support that are required to finish a Ph.D. program. Friends like you are the rarest of commodities. Jen MacLaren, Dr. Robert Decker, Dr. Cheree Padilla, Dr. Guy Nicolette, Dr. Ronald Berry, and Drew were instrumental in ensuring that my life did not fall apart, even if my spine did. Thank you for literally putting me back tog ether again. Your empathetic care provided me with a firsthand example of how to treat patients with orthopaedic trauma injuries. Special thanks also go to the orthopaedic residents and research division staff, especially, Sonya Tang, Barbara Grooms and Stephen Dcruz for assisting with this study. Finally, I will always be grateful for the patients who participated in this study. Your courage and honesty are a source of inspiration and transformed my dissertation from work to a passionate pursuit. I a m humbled and honored to play a small part in your rehabilitation.

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6 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES ............................................................................................................ 8 LIST OF FIGURES .......................................................................................................... 9 LIST OF ABBREVIATIONS ........................................................................................... 10 ABSTRACT ................................................................................................................... 11 CHAPTER 1 INTRODUCTION .................................................................................................... 13 Anxiety and Depression in the General Public ........................................................ 13 Statement of the Problem ....................................................................................... 14 Specific Aims .......................................................................................................... 15 Hypotheses ............................................................................................................. 16 Significance ............................................................................................................ 17 Definition of Terms .................................................................................................. 17 2 REVIEW OF LITERATURE .................................................................................... 19 Orthopaedic Trauma Defined .................................................................................. 19 Examination Through the Lens of Rehabilitation Science ....................................... 20 The Evolution of Rehabilitation Science Models ............................................... 20 The IOM Models Relevance to the Current St udy ........................................... 22 The Cornerstone Articles ........................................................................................ 23 Complexity of Injury and Prevalence of Psychological Distress .............................. 23 Ti me Course of Psychological Distress in Orthopaedic Trauma Patients ............... 24 An Emerging Area of Inquiry in Other Countries ..................................................... 25 Gender Differences and Coping Skills .................................................................... 27 Limitation in the Literature ....................................................................................... 28 3 METHODS AND MATERIALS ................................................................................ 29 Participants ............................................................................................................. 29 Instrumentation ....................................................................................................... 30 Multidimensional Scale of Perceived Social Support (MSPSS) ........................ 30 State Trait Anxiety Inventory (STAI) ................................................................. 31 Patient Health Questionnaire2 (PHQ 2) .......................................................... 31 Positive and Negative Affect Schedule (PANAS) ............................................. 32 Beck Depression Inventory Second Edition (BDI II) ......................................... 32 Procedure ............................................................................................................... 33

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7 Data Analysis .......................................................................................................... 36 Hypothesis 1 ..................................................................................................... 36 Hypothesis 2 ..................................................................................................... 37 Hypothesis 3 ..................................................................................................... 37 Hypothesis 4 ..................................................................................................... 37 Hypothes is 5 ..................................................................................................... 37 Hypothesis 6 ..................................................................................................... 38 4 RESULTS ............................................................................................................... 39 Demographics ......................................................................................................... 39 Variables and Data Reduction ................................................................................ 40 H1 Cohort Anxiety and Depression Levels Compared to the General Public ... 40 H2 Self Reported Psychological Distress Following Orthopaedic Trauma ....... 41 H3 Psychological Distress Cores in Patients with and without a History of Psychological D istress Following Orthopaedic Trauma ................................ 41 H4 Anxiety and Depression Correlations with Injury Severity ........................... 42 H5 Impact of Treatment on Psychological Distress Following Orthopaedic Trauma .......................................................................................................... 42 H6 Anxiety and Depression Correlations with Social Support .......................... 42 5 DISCUSSI ON, LIMITATIONS AND FUTURE DIRECTIONS .................................. 45 An Anxious and Depressed Study Cohort ............................................................... 45 Contributing Factors ................................................................................................ 47 A Novel Approach ................................................................................................... 48 A Closer Look at Demographics ............................................................................. 49 Limitations ............................................................................................................... 51 Clinical Connection ................................................................................................. 52 Future Directions .................................................................................................... 53 APPENDIX A: INFORMED CONSENT FORM ............................................................... 55 LIST OF REFERENCES ............................................................................................... 66 BIOGRAPHICAL SKETCH ............................................................................................ 70

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8 LIST OF TABLES Table page 4 1 Location, type and frequency of patients injuries. .............................................. 43 4 2 Prevalence of anxiety and depression in the normal population compared to the st udy cohort following their injury. ................................................................. 43 4 3 General population norms and study cohort means for the STAI, BDI II, PHQ 2 and MSPSS. ........................................................................................... 44

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9 LIST OF FIGURES Figure page 3 1 Study design and flowchart. ................................................................................ 36 4 1 Participants mechanism of injury by percentage. ............................................... 44

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10 LIST OF ABBREVIATIONS BDI II Beck Depression Inventory Second Edition CDC Centers for Disease Control and Prevention DSM IV TR Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision ICF International Classification of Functioning, Disability and Health ICIDH International Classification of Impairments, Disabilities, and Handicaps IOM Institute of Medicine Model ISS Injury Severity Scores MSPSS Multidimensional Scale of Perceived Social Support NIMH National Institute of Mental Health OSMI Orthopaedics and Sports Medicine Institute PHQ 2 Patient Health Questionnaire2 PANAS Positive and Negative Affect Schedule STAI State Trait Anxiety Inventory UFTC University of Florida Department of Orthopaedics and Rehabilitation Tr auma Clinic

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11 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PSYCHOLOGICAL DISTRESS IN PATIENTS WITH ORTHOPAEDIC TRAUMA INJURIES By Robert Tarkington Barnes August 2013 Chair: MaryBeth Horodyski Major: Rehabilitation Science The aim of this investigation was to examine the prevalence, magnitude and contributors of psychological distress in patients suffering from or thopaedic trauma injuries. The absence of research on the topic is unexpected considering the multiple experts todays Level I trauma facilities have at their disposal, and the millions of trauma injuries occurring annually. As such, 50 consecutive parti cipants who met inclusion criteria and had incurred orthopaedic trauma injuries were administered the stateversion of the StateTrait Anxiety Inventory (STAI) and the Beck Depression Inventory Second Edition (BDI II) following their hospital discharge at a scheduled inclinic trauma appointment. Patients with severe orthopaedic trauma injuries were asked to participate. Severe was defined as patients who sustained multiple fractures, received more than one surgical procedure, and stayed multiple days i n the hospital while rehabilitating their orthopaedic trauma injuries. Results indicated that the prevalence and magnitude of psychological distress in the study cohort far exceeded norms established in the general population. Of note, each participant experienced elevated levels of anxiety (STAI = 63.2 7.1) while 92% of the study cohort suffered from moderate or severe depression (BDI II = 29.8 8.6 )

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12 In all, 94% of patients self reported that they believed psychological distress was caused or exacerbated by their orthopaedic trauma injury. Due to the prevalence and magnitude of psychological distress in the study cohort, no significant differences in anxiety or depression scores were found for those with a prior history of psychological distre ss compared to participants without a history. Furthermore, no correlation was evidenced between Injury Severity Scores (ISS) and anxiety or depression. Unexpectedly, participants receiving treatment for their psychological distress did not differ from p articipants who did not. Finally, significant negative correlations were evidenced between social support and anxiety and social support and depression. Participants with less social support as measured by the Multidimensional Scale of Perceived Social S upport (MSPSS) experienced greater anxiety and depression scores. Considering the prevalence and magnitude of psychological distress in the study cohort, traumatologists should consider adopting an interdisciplinary team to help restore optimal physical r ecovery, to assist in ameliorating psychological distress, and to provide empathetic and complete care

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13 CHAPTER 1 INTRODUCTION From the moment of injury, the wheels of trauma care are set in motion with two overar ching goals acting as guidance: 1) increasing the likelihood of the patients survival, and 2) minimizing the lasting physical effects of injury. In orthopaedic trauma care the initial medical response is focused on the physical injuries that warranted hospital admission. A dvancements in techn ology, improvements in medical training and innovative treatment procedures have markedly improved patients physical recovery. Indeed, the coordination and continuity that now exists among those providing physical care for orthopaedic trauma patients is impressive. First responders, traumatologists, hospital staff and rehabilitation scientists work in concert to attain optimal recovery. The process of rehabilitating an orthopaedic trauma patient to his or her preinjury lev el of functionality is complex Variables that extend beyond ones physical needs, such as psychological wellness, are now acknowledged as integral components of the rehabilitation process by movement scientists.1 Ad dressing psychological needs, as discussed in the Institute of Medicine model (IOM), helps transition the orthopaedic trauma patient from a state of disability to ability In part, this is achieved by ameliorating the psychological impact of the traumatic incident. Equally important, addressing psychological distress during rehabilitation may diminish the likelihood of the onset of comorbidities triggered by affective disorders (e.g. heart attacks ).2,3 Anxiety and Depression in the General Public The National Institute of Mental Health (NIMH) estimates that over 40 million individuals suffer from depression, anxiety and related disorders in the United States, while the Centers for Disease Control and Prevention (CDC) approximate that roughly

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14 twenty percent of Americans are affected.4,5 The global picture is equally as bleak, with the World Health Organization predic ting that by the year 2020, the number of individuals suffering fro m psychological distress will be outnumbered solely by those suffering from heart disease.6,7 The financial toll of psychological distress in the general public is also significant Previous work estimates that anxiety and depression exact a substantial toll on the U.S. economy by costing $42.3 billion and $83.1 billion, respectively .8 Specifica lly, $26.1 billion of the costs attributed to depression were spent on direct medical treatment, while suicide related mortality costs resulted in $5.4 billion annually. With the increasing prevalence of psychological distress in the U.S., this cost estim ate will likely increase dramatically within the next decade. Statement of the Problem It is likely that few incidents are as likely to serve as a catalyst for creating psychological distress, or exacerbate already present psychological symptomology, as su staining an orthopaedic trauma injury. In the U.S. over 2.8 million trauma patients are hospitalized annually.9 Accordingly, to keep pace with a shifting patient demographic, orthopaedic trauma teams need to be aware of potential effects of psy chological distress on orthopaedic surgery outcomes and functional recovery. While the physical effects and medical treatment for orthopaedic trauma patients are well documented, the psychosocial mechanisms that underpin patients reaction to orthopaedic trauma injuries remain unclear. S cant research exists documenting the post injury experiences of orthopaedic trauma patients and their psychological well being Existing evidence suggests that the psychological disposition following an orthopaedic trauma injury may accurately predict the recover y response, and/or the

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15 likelihood of persistent physical disability .10,11 It is possible that the surgical status of the patient may affect the psychological state as well, as multiple surgeries may be more stressful than singular encounters, but this is not yet known. Estimates range as high as 45% of orthop aedic trauma patients experiencing psychological distress that is clinically significant as well as psychological wellness being compromised out to two years post hospital discharge.12,13 C omplexity of injury may also exac erbate psychological distress, as patients with open fractures and severe lower limb injuries exhibit higher depression scores than those with other injuries.10,11,14 I t is unimaginable that a patients physical injuries would remain untreated for 24 months following injury. But, this is frequently the case with patients plagued with psychological distress as orthopaedic trauma patients often remain undiagnosed, untreated or ignored for multiple years following their return to society.10 Finally, the updated IOM model was published in 1997 and advocated the inclusion of psycho logical variables for progress tracking during rehabilitation and for research outcomes.1 Yet currently, the prevalence, magnitude, and additional contributors to psychological distress a fter orthopaedic trauma are not clear Understanding the relationships between psychological distress, injury severity, multiple surgeries and the trajectory of recovery would help optimize rehabilitation planning and long term functional outcomes after an orthopaedic trauma injury Specific Aims To assess the degree to which orthopaedic trauma patients experienced depression, anxiety and negative affect multiple specific aims and hypotheses were developed. The specifics aims planned were threefold:

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16 1. To determine the prevalence of psychological distress in patients who experienced an orthopaedic trauma injury. 2. To investigate the magnitude of psychological distress in patients who experienced an orthopaedic trauma injury. 3. To investigate the contributors (e.g social support, prior psychiatric history) that ameliorate or exacerbate psychological distress levels in patients who experienced an orthopaedic trauma injury. Hypotheses The below hypotheses contribute to a greater understanding of the prevalence, magn itude and contributing factors associated with psychological distress in orthopaedic trauma patients. With respect to Specific Aim 1 Prevalence, research hypotheses include: 1. Anxiety and depression will be considerably greater in an orthopaedic trauma cohort compared to that of the general public 2. P atients with no pre injury hi story of anxiety and depression will self report that their orthopaedic trauma injury caused their current psychological distress. With respect to Specific Aim 2 Magnitude, research hypotheses include: 3. O rthopaedic trauma injuries will cause significantly greater anxiety and depression in patients with a history of affective disorders compared to patients without. 4. S everity of orthopaedic trauma injury will be significantly asso ciated with anxiety and depression. With respect to Specific Aim 3 Contributors, research hypotheses include : 5. Anxiety and depression would be significantly decreased in patients who have been treated for their symptomology, with treatment being defin ed as talk therapy and/or psychopharmacological medications. This will hold true, irrespective of the time elapsed between orthopaedic trauma patients injury and their data collection. 6. A significant correlation between social support and anxiety, and social support and depression will be evidenced. Orthopaedic trauma patients with greater social support will exhibit less psychological distress as measured by the MSPSS

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17 Significance The dearth of research regarding psychological wellness on orthopaedi c trauma outcomes is unfortunate. The absence of research regarding psychological wellness in orthopaedic trauma patients may have significant ramifications for orthopaedic trauma facilities basing their practices and procedures on evidencebased research. Insight into the psychological disposition of orthopaedic trauma patients may help shift the paradigm of how traumatologists are trained and how they interact wi th and treat their patients. A greater understanding may bring compassion to the examination room reframing the accepted boundaries of current orthopaedic trauma practices by re establishing the link between a healthy mind and a healed body Historically, metrics such as psychological wellness have not been focused on in orthopaedic trauma car e. Now, there is a growing need for traumatologists and care teams to provide optimal, efficient empathetic and complete care. With an extreme shortage of orthopaedic trauma surgeons and decreased time for high quality supplemental training (e.g. psych ological and communication) a deficit in patient care has developed. A growing population coupled with a dramatic increase in patient volume supports the need for optimal orthopaedic trauma care. As such, a premium should be placed on adjuvant training t hat traumatologists receive regarding factors that have been traditionally ignored yet may impact outcomes. Finally, quality research examining the psychological characteristics and distress levels of orthopaedic trauma patients will help identify areas f or clinical care improvement. Definition of Terms Below follows operational definitions of the terms used in the study. Psychological terms were defined using the Diagnostic and Statistical Manual of Mental

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18 Disorders Fourth Edition Text Revision (DSM IV TR ) and the psychological questionnaires used in the experiment .15 20 Trauma was defined by Robinsons text on orthopaedic rehabilitation.21 AFFECT. A pattern of observable behaviors that is the expression of a subjectively exper ienced feeling state (emotion). Common examples of affect are sadness, elation, and anger. In contrast to mood, which refers to a more pervasive and sustained emotional climate, affect refers to more fluctuating changes in emotional weather. ANHEDONIA. The inability to find pleasure from activities one previously found enjoyable. ANXIETY. The apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria (dissatisfaction) or somatic symptoms of tension. The focus of anticipated danger may be internal or external. DEPRESSION. A feeling associated with significant despondency and dejection, accompanied by feelings of hopelessness and inadequacy. NEGATIVE AFFECT. The degree to which an individual feels distressed, upset, guilty, scared, hostile, irritable, ashamed, nervous, jittery, and afraid. POSITIVE AFFECT. The degree to which an individual feels interested, excited, strong, enthusiastic, proud, alert, inspired, determined, attentive, and active. SOCIAL SUPPORT. The physical and emotional comfort provided family, friends, and/ or a significant other. STATEANXIETY. The current state of ones anxiety that may fluctuate from timeto time. TRAITANXIETY. The relatively enduring characteristics of anxiety that a person possesses, or in other words, ones general or enduring level of anxiety. TRAUMA. Injury to the body caused by a sudden exposure to environmental energy that is beyond the bodys resilience.

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19 CHAPTER 2 REVIEW OF LITERATURE Orthopaedic Trauma Defined Robinson21 provides an operational definition of the term trauma. He defines it as, damage to the body caused by a sudden exposure to environmental energy that is beyond the bodys resilience. The origin of the word trauma provides a simpler explanation, as it stems from the Greek word for physical injury The process of caring for patients with orthopaedic trauma injuries also has a long history and has been practiced for thousands of years. Evidence documents ancient Egyptians and Greeks performing medical procedures t hat are now commonplace in todays finest Level I trauma centers, such as amputations and fracture care.21 As stated by Cole and colleagues ,22 the inherent longing for a greater understanding of the rehabilitation process, as well as the intrinsic need for humankind to advance from disability to ability has resulted in marked improvements in interdisciplinary rehabilitation. Ironically, it has been historys darkest and most disturbing mome nts (such as World War I and World War II) that have catalyzed the development of rehabilitation science. Indeed, the same appears to hold true regarding orthopaedic trauma injuries and psychological distress, as by definition, research conducted on this topic, is advanced via tragic circumstances. Traumatic accidents prompt a chain of events that may be perceived as novel (e.g. transportation by ambulance) and stressful (e.g. invasive medical procedures).23 Said events may result in elevated levels of distress in healthier patients not suffering from the deleterious effects of serious traumatic injuries. Thus it can be argued, that a novel experience, coupled with pain, fear, and the uncertainty associated with injury

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20 might be the perfect storm for a patients subsequent psychological distress. Before examining the scant peer reviewed articles germ ane to orthopaedic trauma injuries and psychological distress, it is necessary to provide a framework for understanding how rehabilitation scientists might view the interaction of orthopaedic trauma injuries, psychological distress and disability. To this end, the review of rehabilitation science models is useful. Examination through the Lens of Rehabilitation Science Advancements in the field of rehabilitation science over the last 50 years are impressive. R ehabilitation scientists have exponentially expanded the breadth of knowledge specific to their scientific domain, created and increased the efficaciousness of treatment modalities and have assisted greatly in altering societys perception and treatment of the disabled and injured. Despite these advances, scientists and clinicians have historically overlooked the restoration of mental health as part of the rehabilitative process. Multiple newer rehabilitation models now make amends for this oversight and provide a solid structure for conducting psychological research and clinical interventions. As such, a review of rehabilitation science models follows. The Evolution of Rehabilitation Science Models When looking objectively at the creation and subsequent evolution of models in rehabilitation science, Nagi24,25 is considered the founding father, as hi s quintessential works predate his peers His efforts resulted in the creation of an influential model consisting of four domains The se domains are: active pathology, impairment, functional limitation and disability In order to better understand the m odel, examples of each domain are provided.

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21 Active pathology refers to basic science research such as clinicians conducting research on problems specific to t he molecular or cellular level. The next domain in Nagis model is referred to as impairment. Ex panding in scope, impairment pertains to an organ or organ systems. It may also include an individuals loss of mental, physiological, or biomechanical functions. Functional limitation is the third construct within Nagis model and may best be summed up as an individuals hampered abi lity to perform a given task. The final domain in the Nagi model is referred to as disability and differs from impairment, in that it applies to social rather than organismic functioning. In essence, disability is the co mposite of multiple factors impacting the individual within an ecologically valid context. I t is within this domain that the study of psychological distress and patients suffering from orthopaedic trauma injuries would fall Nagis work was revolutionary in that it provided a springboard for rehabilitation scien tists to advance their work. As e xpected, and largely due to being one of the earliest attempts at creating a model, Nagis work has been criticized. Nagis critics argue that his model fails to c reate a, framework of four disti nct but interrelated concepts as he claims.26 This is frequently debated, as the models ability to delineate where one dom ain begins and another ends is not obvious to several scholars. Moreover, it has been suggested that Nagi fails to recognize the multidirectional nature of the rehabilitation process.1 T his becomes increasingly evident when more recent and comprehensive models are directly compared to Nagis work. The International Classification of Impairments, Disabilities, and Handicaps ( ICIDH) was spawned by work that was being conducted in Europe by the W orld Health Organization.26 This model is similar to Nagis24 in that it differentiates between three

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22 distinct yet related dimensions impairments, disabilities, and handicaps As discussed by Jette26, this was intended to produce an etiological framework for classifying disabilities Critics highlight the inability of the model to account for environmental factors a s a shortcoming. Thus, the International Classification of Functioning, Disability and Health (ICF) was created. The ICF model presents a biopsychosocial view by recognizing contextual factors necessary to the rehabilitative process .26 Likewise, the term health condition was implemented to define the cause of the problem ( such as orthopaedic trauma injury or disease). To date, the biopsychosocial view remai ns an often used model for framing rehabilitation science research. The IOM Models Relevance to the Current Study As previously discussed, t he IOM model is logically constructed and accounts for multiple shortcoming s overlooked by Nagi and others .1 In particular, the creation of interwoven transitional factors allow for a more complete and useful model. The flexibility of movement between the domains within the IOM model aids it in being implemented as a framework for conducting science or rehabilitating patients. In sum, this subtle yet elegant revision takes into consideration that rehabilitation is a dynamic and fluid process. Its utility is also evidenced in the transitional factor s being presented in a simple and straightforward schematic. Equally important, the IOM contains a no disabling condition. This is appealing to the rehabilitation scientist, as increasing a patients quality of life is the guiding principle for those charged with bettering the outcomes of patients suffering from orthopaedic trauma injuries. Additionally, the bidirectional arrows within the IOM model help s explain how research implications predict a trend away from disability and toward ability mak ing it a useful model for investigating

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23 psychological distress in orthopaedic trauma patients. In summary, the utility of a model is best judged by its ability to frame and predict aspects related to ones gi ven area of scientific inquiry. For these reas ons, the IOM was adopted for the current research study. Next follows a review of the limited research studies specific to psychological distress in patients suffering from an orthopaedic trauma injury. The Cornerstone Articles Mattisson 27 established the correlation between injury and psychological distress over three decades ago, yet little has been done to f ollow up his originating work. Some exceptions do exist, but these studies are now either dated or answer tangential questions less germane to todays traumatologist (e.g. travel anxiety in patients who experience motor vehicle collisions).28,29 While there are multiple challenges when conducting psychological research on patients with orthopaedic trauma injuries, peer reviewed articles on the topic do exist. Thus, the cardinal papers relevant to orthopaedic trauma injuries and psychological distress are discussed next. Complexity of Injury and Prevalence of Psychological Distress Crinchlow and colleagues12 examined 161 patients who incurred a traumatic orthopaedic injury, investigating how degree of injury and levels of depression are associated. Using the AO Fracture Classification, the Injury Severity S core (ISS) the Abbreviated Injury Scale (AIS) and Gustilo and Anderson score for open fractures, injury severity was correlated with depression scores obtained via the BDI. Patients levels of depression experienced were significant, especially when compared to those of the general public who experience depression at a level from 3.2% to 19.8%. Fifty five percent of trauma patients reported minimal depression, while 28% and 13%, were classified as suffering from depression ranging from moderate to severe,

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24 respectively.12 Moreover, 45% of individuals experienced psychological distress that was clinically significant. Additional findings indicated that open fractures were associated with higher depression scores, suggesting that complexity of injury may intensify psychological distress. The study was significant for multiple reasons. First, it attempted to differentiate psychological symptomology ex perienced. In this case, depression was examined as opposed to more global constructs such as quality of life. Second, it established prevalence rates for depression according to magnitude of symptomology, ranking depression along a continuum from low to severe. McCarthys 10 findings echoed that complexity of injury should be considered when understanding the relationship between poor mental health and orthopaedic trauma injuries, as severe lower limb injuries were correlated with higher psychological distre ss. Not surprisingly, additional findings suggest that depression is not the lone affective disorder experienced by trauma patients. Evidence of anxiety and Posttraumatic Stress Disorder (PTSD) have been documented in patients treated by orthopaedic unit s.11 Of note, both disorders have been identified as strong predic tors of poor physical recovery and ongoing disability. Ti me Course of Psychological Distress in Orthopaedic Trauma Patients Level I evidence collected across multiple time periods regarding the psychological well being of orthopaedic trauma patients requir e great resources and are limited. One exception is the ongoing work of Sodberg13 who analyzed data obtained from questionnaires such as the Short Form 36 (SF 36) a nd World Health Organization Disability Assessment Schedule II (WHODAS II). In a study of 105 patients admitted to a Level I trauma center, data suggested that physical, social and emotional functioning were significantly compromised in patients long after their injury had occurred (6weeks

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25 post discharge and at oneyear and twoyear post injury assessments). As such, it is evident that psychological distress can be both persistent and/or episodic in orthopaedic trauma patients. An additional study providing Level I evidence echoed the findings of Sodberg. Five hundred sixty nine trauma patients enrolled from eight Level I trauma centers were administered the Brief Symptom Inventory (BSI), which quantifies levels of distress.10 Results indicated only a six percent decrease in the number of individuals experiencing psychological distress twoyears following their traumatic injury (from 48% to 42%). Furthermore, they found that twoyears post injury only 22% of patients reported receiving psychological services of any kind to help ameliorate their psychological distress. Finally, Gustafsson, Windahl, and Blomberg,30 examined psychological distress in patients with an acute hand injury.30 Patients completed questionnaires via mail at specific time increments following their injury with results suggesting that patients exhibiting ps ychological distress for longer than three months should be referred to appropriate psychiatric services. An Emerging Area of Inquiry in Other Countries Countries outside the U.S. are taking the lead in understanding the link between orthopaedic trauma injuries and psychological distress. While much of this research has methodological issues and reaches a lower level of evidence, worthwhile findings are being documented. In addition to previously mentioned articles such as Sodbergs work in Norway and Gustafssons research in Sweden, multiple researchers in Japan, Korea and the UK appear to be interested in how lessening psychological distress can assist patients within their healthcare systems.13,30 33

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26 Japanese researchers have attempted to identif y whether personality differences between orthopaedic and nonorthopaedic patients exist.31 Using the Maudsley Personality Inventory, orthopaedic and nonorthopaedic patients were found to have similar personalities, but orthopaedic trauma patients exhibited a higher percentage of eccentric behaviors such as ne uroticism. Confounding the study was the fact that all personality inventories were collected after the injury, with no attempts made to capture the personality of their patients prior to the time of injury (through health records or other archival evidence). A study in Korea compared patients with distal radius fractures who had undergone volar plating or cast immobilization.32 No difference was found in patient depression levels based on type of fr acture care received. However, a secondary finding was clinically relevant as pain was identified as an accurate predictor of depression. Therefore, early screening for psychological distress in patients with high pain levels should be considered. Similar results were found in a 2012 UK study conducted by Wood, Maclean and Palliester.33 The researchers found that anxiety and depression were correlated with patients pain ratings. A possible limitation of the study was the authors suggestion regarding the dir ection of the relationship between pain, anxiety and depression. As delineated in the BDI II and DSM IV, multiple somatic symptoms are intricately tangled within the construct that is depression. Thus, teasing out whether depression precedes pain, or vic e versa is impossible via correlation analyses. Nonetheless, the observation that anxiety and depression might lead to a hypervigilant response to somatic symptomology and subsequent lifestyle changes, is of importance to clinicians.

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27 Gender Differences an d Coping Skills Gender differences have also been noted in how trauma patients experience psychological distress. In a largescale prospective epidemiologic study examining multiple outcomes, Holbrook and Hoyt34 found that women have a significantly poorer quality of life compared to that of men, following an orthopaedic traumatic injury. This finding held true at multiple time intervals following the traumatic injury (si x twelve and eighteenmonths post) and after multiple factors including severity of injury, location of injury, whether the injury was blunt or penetrating and whether the injury was intentional or unintentional were controlled for. Examining how individuals cope following a traumatic injury is pertinent to those charged with rehabilitating patients. A metaanalysis by Littleton, Horsley and Nelson35 investigated coping strategies adopted by individual s who experienced a traumatic incident. While few of the thirty nine articles included in the final analyses were specific to orthopaedic trauma injuries, a clear correlation between avoidance coping strategies and psychological distress was witnessed. A voidance strategies can be defined as ignoring the stressor (e.g. orthopaedic trauma injury) or feelings that are resultant from the stressor (e.g. anxiety). Specific actions that would be classified as avoidant behaviors include withdrawing from others, ignoring the thoughts associated with the incident and denying that the stressor exists.36 A UK study echoed these findings as maladaptive coping strategies predicted poorer quality of life in 47 patients with external fixation devic es, while adaptive coping strategies predicted a greater quality of life.37 In general, distinct differences have been witnessed in the types of individuals who seek and are granted mental health help, but trends have also been evidenced in injured populations. Minorities, those with l ess education, lower incomes and addictive

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28 behaviors are less likely to seek psychological assistance, or are more likely to be lost to follow up (Narrow, 2000).38,39 Of note, to the best of our knowledge quality research conducted on the interplay among social support, psychological distres s and orthopaedic trauma injuries have not been collected. Limitation in the Literature The volume of research conducted on patients experiencing orthopaedic trauma injuries is the most glaring limitation when reviewing the literature. The quality of exp erimental design and depth of inquiry in the aforementioned research were also disparate. Some studies appeared to be executed with a more watchful eye and rigorous design. Yet others were ambiguous regarding crucial details such as inclusion/exclusion c riteria and rationale for the psychological inventories implemented. The current study aims to add to the knowledge base regarding the psychological distress experienced by patients sustaining an orthopaedic trauma injury while considering the previously mentioned shortcomings

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29 CHAPTER 3 METHODS AND MATERIALS Participants In all, 50 patients participated in this prospective cohort study. A sample of convenience of injured orthopaedic trauma patients that met inclusion criteria was adopted English sp eaking patients between the ages of 18 to 80 who were receiving follow up care for an orthop aedic trauma injury were eligible for inclusion in the study. Patients with severe orthopaedic trauma injuries were included. Specifically, this was defined as pat ients who received multiple surgical procedures for their orthopaedic injuries. These patients were selected due to sustaining multiple fractures, staying multiple days in the hospital and/or recuperating for an extended time period at a rehabilitation facility or at home. To avoid selection bias, 50 consecutive patients who met these criteria were accepted into the study. ISS scores were only accessible following patients granting their consent, thus, this metric was not used to select participants a pr iori Sample size was determined by an a priori analysis using the G*Power general power analysis program .40 The alpha level was set at .05 with a corresponding power of 0.80 to detect a medium effect size on anxiety. A medium effect size was selected according to the convention established by Cohen41 for estimating effect size i n the absence of existing data. Hence, a sample size of 50 was shown to be appropriate to address the primary research question. Participants were selected from the total sample of patients seeking treatment over the course of one year at the University of Florida Department of Orthopaedics and Rehabilitation Trauma Clinic (UFTC) at the Orthopaedics and Sports Medicine Institute (OSMI). The UFTC cares for patients

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30 discharged from the Level I Trauma Center at Shands Hospital in the Universit y of Florida Healthcare System. This hospital serves a population base that geographically reaches patients in all 67 Florida counties, multiple states and over 12 countries annually. Patients were excluded from t he study if they sustained a traumatic brain injury that resulted in lasting cognitive impairments. Additional exclusion criteria included patients that lacked the ability to communicate effectively (e.g., at a level where self report measures could be answered completely). Finally, patients that were psychotic or suicidal were also denied inclusion into the study and were immediately seen by a healthcare professional and referred for additional psychological care. In all, 92% of patients contacted consented to participate in the study, while two patients data were discarded due to unintentional variations in the study protocol. Instrumentation Self report measures were employed as the primary method for quantifying patients psychological distress fol lowing an acute orthopaedic trauma injury. As opposed to implementing inventories based on convenience, the questionnaires implemented in the current study are considered the gold standard in the field of psychology and have a long history of implementa tion in multiple research settings. Accordingly, the MSPSS,20 the state version of the STAI,18 the Patient Health Questionnaire2 (PHQ 2),17 the Positive and Negative Affect Schedule (PANAS),19 and the BDI II,16 were implemented. M ultidimensional Scale of Perceived Social Support (MSPSS) The MSPSS measures participants perceived level of social support. The inventory is comprised of 12 items quantifying three subscales of perceived support:

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31 family (e.g., father, mother, brother or sister), friends and significant others (e.g., wi fe or husband). Subjects completed each question by circling the appropriate response that best answered each question. Answers were formatted on a 7point Likert scale ranging from very strongly disagree to very strongly agree. Participants overal l score were comprised by totaling their response to all questions, while subscales can be scored by totaling participants responses and dividing by the number of questions within a given subscale. The reliability score for the inventories total score is 91, while the reliability scores for each of the subscales range from .90 to .95.20 State Trait Anxiety Inventory (STAI) The state v ersion of the STAI assesses transient levels of anxiety. The inventory is a unideminsional tool for assessing anxi e ty, with an individuals stateanxiety score calculated by totaling scores on differing questions assessing several components of anxiety including: apprehension, tension, nervousness, and worry. The inventory was comprised of 20 questions scored on a 4point Likert scale. Due to the ephemeral nature of stateanxiety, low reliability scores (0.16 to 0.62) confirm its utility in tracking the transient nature of stateanxiety.18 Patient Health Questionnaire 2 (PHQ 2) The PHQ 2 is a twoitem inventory implemented as an initial step for assessing depression and anhedonia. The inventory consists of t he first two questions of the Patient Health Questionnaire9 and explicitly asks patients to consider the last two weeks when completing answers. The questionnaire has been shown to be useful in clinical settings where short form questionnaires assist w ith mitigating time demands placed on clinicians .17 The inventory correlates strongly with the BDI II. Possible

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32 answers are presented on a 4 point Likert scale ranging from not at all to nearly every day The inventory is scored by totaling the responses to both questions.17 Positive and Negative Affect Schedule (PANAS) The PANAS is a 20 question self report measure quantifying positive and negative affect on a 5point Likert scale. The 10 positive affects are: interested, excited, strong, enthusiastic, proud, alert, inspir ed, determined, attentive, and active. The 10 negative affects are: distressed, upset, guilty, scared, hostile, irritable, ashamed, nervous, jittery, and afraid. Both the positive and negative affect subscales are scored by calculating the aggregate of t he 10 positive and 10 negative answers. The test retest reliability of the positive affect and negative affect scales are 0.89 and 0.85, respectively.19 The PANAS question rating strong was the only question of interest as it allowed participants to self rate their physical recovery at the point of intake. Beck Depression Inventory Second Edition (BDI II) Given the comorbidity between anxiety and depression, the BDI II16 was administered to delineate the two conditions. The BDI II measures characteristic attitudes and sympt oms associated with depress ion. The inventory consists of 21 items each rated on a 4point scale with 0 being the lowest score and 3 being the highest score for each item presented. Total scores above 30 are i ndicative of severe depression. The measure is routinely implemented and found to be reliable 0.93.16 The BDI II was crea ted using the characteristics and symptomology associated with depressed individuals as defined by the DSM IV

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33 Procedure The University of Floridas Institutional Review Board approved all procedures and participants provided written informed consent (App endix A) prior to participating in the study. Psychological data were collected during patients sch eduled clinic visit to the UFTC. Prior to checking in for their scheduled visit, patients were nave to the study and that they may be asked to participat e. As is standard procedure, upon arrival to the UFTC participants were greeted by medical staff and asked to complete requisite forms updating their medications and symptomology. In all cases, x rays to assess patients rehabilitation were completed nex t. Patients were then escorted to a quiet patient examination room by a Trauma Clinic nurse where they waited to be examined by the Trauma Physician Assistant or Orthopaedic Trauma Resident and finally by the Chief of the Orthopaedic Trauma Service. Once patients were seated comfortably in their examination room they were introduced to the researcher. The researcher was a member of the Orthopaedics and Rehabilitation Trauma Team trained in psychology and in the collection of quantitative and qualitative data. Formal introductions were made to each potential participant in an identical manner. To assuage patients concerns associated with being in a medical setting and being asked deeply personal questions, and to help ensure that honest answers were giv en, special attention was paid to reiterate the following points while consenting a prospective participant: 1) responses would remain completely confidential and deidentified to everyone but the researcher (unless, suicidal ideations or the intent to harm others was explicitly stated), 2) participants would not incur any financial costs for participating in the study, and 3) participants responses to psychological questions

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34 would no way impact the type, or quality of healthcare they received during their scheduled (or future) visit. Patients were also informed that they would receive no direct compensation for participating, but rather that indirect benefits may include: 1) helping researchers and future patients understand the psychology associated with traumatic orthopaedic injuries, and 2) while occasionally it has been reported that recounting traumatic events can be emotionally disturbing, patients frequently state that they feel better or relieved after discussing the circumstances surrounding t heir traumatic incident with a trained professional. Once patients questions and concerns had been addressed and the experimenter obtained written informed consent data collection commenced. Participants were next asked to complete a Demographic, Healt h Behavior and Medical Information Form. Upon completion of the form, the MSPSS, STAI, PHQ 2, PANAS and BDI II were administered. All forms were given to each patient with the experimenter reading the directions and questions aloud. The experimenter also recorded patients verbal responses to questions. Pilot testing indicated that some patients needed assistance from the experimenter due to the type (e.g. upper extremity fractures) or severity of their injuries. Thus to remain consistent, this procedur e was repeated with each participant regardless of injury. This method varies from most largescale epidemiological studies that do not allocate the requisite resources and time (up to 45 minutes) to use staff members to read the directions and questions for each questionnaire. Precedence has been established for this more thorough approach, as the PHQ 2 has been administered via verbal directions.17 The qualitative training of the researcher also ensured that data collection was completed in a consistent manner.

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35 Following the completion of the psychological inventories patients were prompted via an openended question to briefly discuss the circumstances leading up to, and following, their orthopaedic trauma injury. They were informed that answering this question was optional and would not preclude them from being involved in the study. Complete and rich qualitative responses, such as the mechanism of injury (e.g. gunshot wound), the decision making process that precipitated their orthopaedic injury (e.g. drunk driving), mitigating or exacerbating circumstances (e.g. drug use), whether additional individuals were injured or killed in the acci dent, and the recovery process were discussed in specific detail. Each patient was given the openended question and was allowed to elaborate on their answer until they felt the question had been sufficiently answered. Each patient enrolled in the study agreed to answer this question. Finally, patients questions and comments were addressed and participants were thanked for their involvement. Answers to questions were stored in patient folders Folders included an experimenter checklist to ensure that 1) data were collected in the proper order, 2) patient responses to qualitative questions were present 3) medical records describing the operative procedure(s) performed were present, and 4) the Demographic, Health Behavior and Medical Information sheet, c urrent medications prescribed and answers to the psychological inventories were present. Patient folders were stored in a locked file cabinet within the Department of Orthopaedics and Rehabilitation. Data from completed patient folders were then entered into REDCap for secure storage and for latter analyses.

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36 Figure 31: Study design and flowchart Data Analysis SPSS version 21.0 (Chicago, IL) was implemented for all statistical analyses. Statistical significance was set a priori at p<.05 Hypotheses and how they were analyzed follow below. Hypothesis 1 Anxiety and depression scores would be considerably greater in an orthopaedic trauma cohort compared to that of the general public. Descriptive statistics including frequency and percentages were used to compare prevalence of psychological distress

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37 in orthopaedic trauma patients to generalized norms established by epidemiological reviews Hypothesis 2 Patients with no preinjury history of anxiety and depression would self report that their orthopaedic trauma injury caused their current psychological distress. Descriptive statistics including frequency and percentages and self report data were used to quantify the number of patients who reported that their orthopaedic trauma injury acted as a catalys t for their psychological distress. Hypothesis 3 Orthopaedic trauma injuries would cause significantly greater anx iety and depression in patients with a history of affective disorders compared to patients without. Two separate independent samples t tests w ere performed to compare the effect of patients psychiatric his tory on psychological distress. The t tests conducted were psychiatric history x anxiety and psychiatric history x depression. Hypothesis 4 A significant correlation bet ween injury severity and anxiety and injury severity and depression would be evidenced. Orthopaedic trauma patients with more severe injuries would exhibit increased psychological distress as measured by the STAI and BDI II. Separate Pearson Product Moment correlation analyses were calculated to assess the relationship between injury severity and anxiety and injury severity and depression. Hypothesis 5 Anxiety and depression would be significantly decreased in patients who had been treated for their symptomology, with treatm ent being defined as talk therapy

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38 and/or psychopharmacological medications. This would hold true, irrespective of the time elapsed between orthopaedic trauma patients injury and their data collection. Two separate independent samples t tests were conducted to compare the effect of patients psychiatric treatment (treatment, no treatm ent) on psychological distress. The t tests performed were psychiatric treatment x anxiety and psychiatric treatment x depression. Hypothesis 6 A significant correlation be t ween social support and anxiety and social support and depression would be evidenced. Orthopaedic trauma patients with greater social support would exhibit less psychological distress as measured by the Multidimensional Scale of Perceived Social Support. Separate Pearson Product Moment correlation analyses were calculated to assess the relationship between social support and anxiety and social support and depression.

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39 CHAPTER 4 RESULTS Demographic data for participants are discussed first in this chapter. This is followed by the prevalence of psychological distress in the study cohort. These scores are presented alongside established norms for the general public. Descriptive and observational data are presented to examine whether patients suffering fr om orthopaedic trauma injuries felt as if their orthopaedic injury caused their depression and/or anxiety. Next, depression and anxiety scores are compared between patients with a history of psychological distress to those without. Severity of orthopae dic trauma injury is then analyzed to determine if it correlated with anxiety and depression scores. Finally, therapeutic methods and social support were analyzed independently to see if they ameliorated depression and anxiety. Demographics Fifty participants (30 females, 20 males; mean age 43.2 years, 13.2) completed the study. Participants mean education was grade 11.3 1.9. The ethnicities of participants were 46 Caucasians, two Hispanics and two African Americans. Marital status of participants included 22 married, 16 single, seven divorced and five cohabitating. Due to the severity of injuries, only one participant reported that she had returned to work at the time of intake. Maladaptive coping mechanisms were calculated with nicotine consumption (packs per day) and alcohol consumption (drinks per week) equaling .41 .51 and 3.4 12.3, respectively. All participants underwent multiple surgical procedures and were hospitalized for an average of 12.85 11.26 days. The aforementioned hospitalization time does not include the oftenlengthy stays that participants had in rehabilitation facilities. The mean

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40 elapsed time between participants hospital discharge date and collection of data was 159.3 238.8 days. The average ISS score was 15.9 12.1. Two hundred and nine injuries sustained were fractures with the majority occurring to the lower extremities (Table 41). In total, 287 injuries were diagnosed with each patient averaging 5.7 injuries incurred. The most common mechanisms of injury were related to motor vehicle and motorcycle accidents, together they accounted for 64% of all participant injuries (Figure 4 1). Variables and Data Reduction The primary dependent variables measured were stateanxiety (STAI) and depression (BDI II) score s. The primary independent variables selected were participants history of psychological distress (history, or no history), severity of orthopaedic trauma injuries (ISS), whether participants received treatment for their psychological distress following their orthopaedic trauma injury, and participants level of social support (MSPSS). H1 Cohort Anxiety and Depression Levels Compared to the General Public Pre valence of anxiety and depression in the general population compared to the study cohort following their injury are presented in Table 42, while population norms and study cohort means for the STAI, BDI II, PHQ2 and MSPSS are described in Table 4 3. Based on mean scores, participants were classified as having high anxiety (STAI = 63.2 7.1) severe depression (BDI II = 29.8 8.6 ) and low social support (MSPSS = 3.9 1.6) These scores were significantly worse than established norms for the general population (Table 43). The percentage of the study cohort suffering from anxiety (100%) and some degree of depression (98%) also greatly exceeded that of the U.S. population 18.1% and 9.5%, respectively (Table 42).

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41 Prior to their accident, the percentage of the study cohort that was clinically diagnosed with anxiety (26%), depression (22%) or a combination of anxiety and depression (18%) mirrored established percentages in the general population (anxiety 9.5% and depression 18.1%). One participant had been hospitalized prior to their orthopaedic trauma injury for psychological issues. This number c oincides with the national population that indicates 995 per 100,000 U.S. citizens are hospitalized annually for psychological issues.42 H2 Self Reported Psychological Distress Following Orthopaedic Trauma Thirty five participants (70% of total sample) self reported no history of psychological distress prior to their orthopaedic trauma injury. Thirty three of these participants (94%) self reported that they believed psychological distress was caused by their orthopaedic trauma injury. All 15 participants (30% of total sample) with a history of psychological distress believed that their orthopaedic injury resulted in a relapse of psychological distress (if it had previously been resolved) or that the injury exacerbated their current symptoms. In all, 30 participants where clinically diagnosed with psychological distress following their orthopaedic injury (anxiety 38%, depression 42% or combination of anxiety and depression 26%). These percentages were confirmed by participants medical records data. H3 P sychological Distress Scores in Patients with and without a History of Psychological Distress Following Orthopaedic Trauma An independent samples t test was conducted to compare anxiety in participants with a history of psychological distress to participants without a history of psychological diagnoses. No significant difference in anxiety scores as measured by the STAI for those with a prior history of psychological distress (M=64.1 5.8) and participants

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42 without a history of psychological distress (M=62 .9 7.6); t(48) = .55, p = .58 was evidenced. The same trend held true for depression as measured by the BDI II, as no significant difference was found between those with a prior history of psychological distress (M=30.4 6.6) and those without (M=29.6 9.4); t(48) = .30, p = .77. H4 Anxiety and Depression Correlations with Injury Severity A Pearson product moment correlation coefficient was conducted to analyze the relationship between anxiety and injury severity as measured by the Injury Severity Score. No significant correlation between the variables was found r = 0.08, n = 40, p = .593. With respect to depression and injury severity, the same trend held true r = 0.08, n = 40, p = 608. In sum, no correlation was found between anxiety and depr ession scores and injury severity. H5 Impact of Treatment on Psychological Distress Following Orthopaedic Trauma Two independent samples t tests were conducted to compare if treatment of psychological distress following an orthopaedic trauma injury amelior ated anxiety and depression. There was no significant difference in anxiety scores for those who received treatment (M=64.1 7.3) and participants who did not receive treatment (M=62.3 6.7); [t(48) = .91, p = .36]. Analysis of depression scores were similar, as no significant difference was found between those who received treatment (M=30.5 8.0) and those without (M=29.2 9.2); [t(48) = .51, p = .61]. As such, it is apparent that the treatment obtained by participants in the study cohort did not adequately ameliorate either anxiety or depression. H6 Anxiety and Depression Correlations with Social Support A Pearson product moment correlation coefficient was conducted to analyze the relationship between social support and anxiety. A significant cor relation between the

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43 two variables was evidenced r = 0.28, n = 50, p = .048. A correlation between social support and anxiety was witnessed as participants with higher anxiety scores had decreased social support. A correlation between depression and soc ial support was also evidenced, r = 0.47, n = 50, p < .001. In sum, a negative correlation between social support and depression was evident as those with elevated depression scores tended to have less social support than those with lower scores. Table 4 1. Location, type and frequency of patients injuries. Location & Injury Frequency Total: 287 Totals Skull/Spine Thorax Arm Pelvis Femur Lower Leg Foot Fractures 209 32 62 23 18 19 42 13 AKA BKA UE Toe Amputations 8 3 3 1 1 Organ Joint Infection Laceration/Wound Vascular Blinded Other 70 15 14 12 24 4 1 Table 42 Prevalence of anxiety and depression in the normal population compared to the study cohort following their injury U.S. Population 6,43,44 N=296,410,404 Study Cohort N=50 Anxious: (STAI>40) 6 18.1% 100% Depressed: (BDI II) 44 0 13: NoneMinimal 14 19: Mild 20 28: Moderate 29 63: Severe 9.5% 2% 6% 44% 48%

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44 Tabl e 43 General population norms and study cohort means for the STAI, BDI II, PHQ 2 and MSPSS Inventory General Norms Cohort Mean (sd) Classification based on Score STAI Males: 35.7 (10.4) 18 Females: 35.2 (10.6) 18 63.2 (7.1) 45 BDI II 9.11 46 29.8 (8.6) Severe Depression ( 29) 16 PHQ 2 a 4.4 (1.8) Positive Depression ( 3) 17 MSPSS 5.58 20 3.9 (1.6) Lower scores reflect less social support a No established general population norms in the literature as cl inical cutoffs are used. Figure 41. Participants mechanism of injury by percentage.

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45 CHAPTER 5 DISCUSSION, LIMITATIONS AND FUTURE DIRECTIONS In summary, the STAI and BDI II questionnaires were administered to patients who had suffered severe orthopaedic trauma injuries that resulted in multiple surgeries and/or multiple fractures. Participants data was collected by a member of the orthopaedic trauma team during the patients inclinic visit to the UFTC. Consistent an d elevated anxiety and depression scores made comparisons between participants with a history of psychological distress and without a history of psychological distress problematic. This was also true for the relationship between injury severity scores and anxiety and depression, and analyses regarding treatment A discussion of the results, limitations and future directions follows. An Anxious and Depressed Study Cohort Without question, the crucial findings of the study were the alarming prevalence and magnitude of anxiety and depression experienced within the study cohort. Indeed, it was this persistent finding across patients, irrespective of differentiating variables that confounded additional comparisons. The percentage of the study cohort sufferi ng from anxiety (100%) and depression (98%) greatly exceeds that of the U.S. population 18.1% and 9.5%, respectively (Table 42). The magnitude of psychological distress is also impressive as participants were classified as having high anxiety (STAI = 63. 2 7.1) and severe depression (BDI II = 29.8 8.6 ). On average, the STAI scores were 23 points greater than the cutoff point frequently used to classify an individual as highly anxious.18,45 The PHQ 2 was implemented as a method of checks and balances for the BDI II data and to ensure the integrity of the data. The mean PHQ 2 score (4.4 1.8) echoes data obtained from the BDI II, as the clinical cutoff for positive depression is a

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46 score greater than three.17 All questionnaire scores obtained were markedly worse than the established norms for the general population (Table 43) illustrating that the st udy cohort under investigation was under significant psychological distress. The psychological distress reported is also far greater than that described in prior research on the topic.12 Crinchlow reported that 45% of trauma patients reported psychological distress that was clinically significant. Factors accounting for the discrepancy between the aforementioned study and the current investigation may include the level of injury severity, the number of fractures sustained, the multiple surgical procedures experienced, and the decreased social support among this studys participants. Often overlooked by other researchers and not discussed in any pr ior literature that could be found, was the propensity for larger studies to obtain data via methods that are less conducive to building rapport and trust between the patient and researcher. Thus, it is possible that the severity and prevalence of psychological distress were underreported in prior studies. The researcher in the current investigation was an embedded member of the orthopaedic trauma team who was familiar with the patients and had interacted with them prior to their hospital discharge. Thus, it can be safely assumed that in most cases an atmosphere of trust was established prior to intake, decreasing the likelihood of psychological distress being underreported. The current study does coincide with the work of McCarthy,10 who found that patients with lower extremity injuries experienced significantly greater psychological distress. The Chief of Orthopaedic Trauma supervising the UFTC primarily treats lower extremity injuries. Thus, the majority of patients seeking care in the current study were

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47 being seen for lower extremity fractures. Additional support for lower extremity patients experiencing elevated levels of psychological distress comes from participants responses to the PANAS gauging how physically strong they felt. On average, participant s reported a score of 2.6 (rated on a 5point Likert scale). Translated into words, this score would classify their average strength rating as falling between a little to moderate.19 Responses from the openended question that followed the completi on of participants questionnaires shed light on these responses, as several participants cited their lack of ambulation as the root cause for their poor strength rating and comorbid psychological distress. Contributing Factors Twenty four patients self reported that they received psychological services after their orthopaedic trauma injury. Of these, none received extensive talk therapy, or talk therapy without psychopharmacological medications also being prescribed. Seventeen percent of patients recei ving treatment for their psychological distress did so with talk therapy and medications, meaning the remaining 83% were treated exclusively with medication. With the vast majority of patients lacking a primary care physician, being out of work and uninsured, the task of obtaining long term medications and/or talk therapy was unlikely. When this is coupled with the fact that resources such as hospitalizations for those under psychological distress have decreased steadily due to a lack of hospital beds and more stringent insurance criteria5, the prognosis for these patients long term psychological well being is not good. It would be presumptuous to assume that medications do not ameliorate anxiety and depression. Pharmacological solutions may not be the panacea, but they have been shown to be effective in at least temporarily ameliorating the burden of anxiety and

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48 depression.15 Under t he current studys structure, it was impossible to know how long patients adhered to taking psychiatric medications that may have been prescribed at the time of their hospital discharge and the true reason their doctor prescribed the medication. Despite a limited sample, data strongly indicates that medications alone might not be strong enough to treat the root causes of psychological distress, suggesting that throwing medication at the problem cannot solve complex issues like anxiety and depression. Fu ture randomized controlled studies need to incorporate extensive talk therapy interventions to assess their efficacy with patients suffering from orthopaedic trauma injuries. A Novel Approach The current study went to great lengths to investigate participants psychological history prior to their orthopaedic trauma accident. This differs from previous research, which appears to agree that quantifying patients mental health prior to their orthopaedic injury is an inherent limitation when investigating thi s line of research. For this reason, the current study provides a novel contribution. It is also in contrast to the studies presented in the review of literature, which did not allocate the adequate resources and time to research their participants past incidences of anxiety and depression. Sifting through medical records and conducting detailed intake interviews with patients are requisite if accurate data on the subject is to be obtained. Accordingly, aforementioned oversights by prior researchers have significantly delayed a better understanding of the probable interaction between orthopaedic trauma injuries and psychological distress. Inquiring about previous psychological history provides a snapshot of how this studys cohort compares to the gener al public. As previously noted, prior to their accident the percentage of the study cohort that was clinically diagnosed with anxiety,

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49 depression or a combination of anxiety and depression was 26%, 22% and 18%, respectively. This data fell in line with established percentages in the general population (anxiety 9.5% and depression 18.1%).6,44 Following participants injuries, a noticeable shift occurred as 30 participants were clinically diagnosed with psychological distress (anxiety 38%, depression 42% or combination of anxiety and depression 26%). While 96% of all participants reported that that their injury had caused distress, 100% of participants with a history of psychological issues self reported that their orthopaedic injuries resulted in a relapse of psychological distress (if it had previously been resolved), or that the injury worsened their symptoms Thus, researching patients medical records and implementing more detailed patient history provides valuable data and should be considered. If the current study had adopted a research design similar to previous work, the inability to determine the direction of the relationship between orthopaedic trauma injuries and psychological distress would still be ambiguious.33,47 While causal determinations cannot be elucidated by the current studys design, the aforementioned data does provide support for orthopaedic trauma injuries acting as a catalyst for causing psychological distress in patients with orthopaedic t rauma injuries. Thus, this study provided innovative methods for addressing problems that have hindered progress in this area of inquiry. A Closer Look at Demographics A more detailed understanding of the current studys patient demographics is integral t o applying the aforementioned results. Worthy of note, the mean age of the participants in this study was 43.2 years 13.2. This is significant because, according to the National Institute of Mental Health, the average age when the onset of major

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50 depres sion occurs in the general population is 32 years.5 While this number falls within the standard deviation of the study c ohort, it would be expected that most psychological issues that would confound the current studys data would have manifested much earlier in the study cohorts lives. Again, this provides additional evidence that it is likely that orthopaedic trauma injuries cause psychological distress. Equally important, it provides a counterpoint to the critic claiming that orthopaedic trauma injuries tend to find those with psychological issues. This data indicates that those subscribing to this opinion might be i llinformed. It also helps dispel negative stereotypes often attached to those suffering from anxiety and/or depression following an orthopaedic trauma injury. Examining participants level of education is also pertinent in trying to predict whether they will experience psychological distress and how (or if) they might go about seeking treatment. Several of the studys participants failed to graduate from high school ( mean education grade 11.3 1.9) and the number of college graduates within the study c ohort (four) was surprisingly low. Thus, the likelihood of this study cohort seeking psychological services is significantly lower, as it has been documented that low income individuals and those with lower educational levels are less likely to seek treat ment and are often lost during follow up.38,39 As opposed to seeking mental health care that is often not available to them, it has been shown that these individuals often resort to maladaptive coping strategies to treat their psychological distress.36,37 Surprising ly, the frequency of alcohol and nicotine use were low in this studys cohort. This might be attributed to changes made by the patients while they where in the hospital, concerns they might have regarding possible interactions with prescribed medications, or worries that poor lifestyle habits may impede the healing process.

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51 Limitations Inherent limitations exist in studying the psychological state of patients who have suffered an orthopaedic trauma injury. A significant limitation of the current study was the implementation of ISS to analyze the relationship between anxiety and injury severity, as well as depression and injury severity. It has been argued that alternative options such as the Abbreviated Injury Scale more accurately depict patients level of injury and should be considered in future research designs.48 Additional limitations include the lack of a true randomized design or a comparison group. This criticism is not easily resolved, as the resources necessary to implement a true r andomized study in this line of research would need to be substantial. With that being stated, collecting participants data at multiple time points might bolster future studies, providing a rich and detailed account of the orthopaedic trauma patients ps ychological experience. Moving Forward Currently there are few programs that embed rehabilitation scientists within orthopaedic trauma teams. Indeed, it was the recognized lack of resources by the UF Department of Orthopaedics and Rehabilitation that helped prompt the current research study. Thus, employing individuals who are trained in collecting psychological data while helping patients transition from disability to ability should be considered a priority. Additional obstacles preventing a more ind epth understanding of psychological distress in orthopaedic trauma patients might also be overcome if increasing resources are allocated. The preponderance of trauma injuries (e.g. car accidents) occur at night and on weekends, times when access to psychological services for both patients and their families are limited. Clearly this creates a delay in the ability to assess psychological distress and provide mental health services for patients. It is also problematic for time-

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52 sensitive studies that are interested in the assessment of individuals psychological symptomology immediately following injury. Moreover, trauma patients are often injured and/or treated far from their residence, making follow up visits that may provide assessment and care difficult Advancements in technology provide a potential solution to this problem as systems such as Telehealth, the delivery of healthcare services through telecommunications, become increasingly feasible. Clinical Connection The current study provides supporting evidence for traumatologists and orthopaedic trauma clinics to adopt a more humanistic approach toward patient care. Humanism is defined as focusing on the needs, well being and interests of a person, particularly their dignity and worth. When applied to medicine, humanism aims to treat the whole patient healing their physical injuries while nurturing and restoring their sense of self. In order to do this effectively, it requires a multidisciplinary team, each operating under the aims of providing int egrated, empowering and complete patient care. The current model of fractured healthcare runs juxtaposed to these ideas. In order to continue to work toward achieving this end, it is recommended that the following steps be considered by those charged wit h overseeing orthopaedic trauma care: 1. Implementing multidisciplinary orthopaedic trauma teams that foster integrated care, whereby the whole patient is the focus of treatment. 2. Guidance for orthopaedic trauma teams in the compassionate appli cation of the pr actice of medicine through continual training and education. 3. Continued i dentification of variables that are often overlooked in orthopaedic trauma that frequently confound the healing process, while also detracting from patients self worth (e.g. psycholog ical distress). By working to achieve these goals, the traumat ologists and healthcare staff will be better equipped to treat their patients While this is an essential area of inquiry, simply

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53 identifying psychologic al distress in trauma patients without i mplem enting a mechanism for change would be insufficient. Thus, additional training is required for tomorrows orthopaedic trauma teams. With a concerted effort focus ed on empathetic care healthcare providers trained in understanding the psychological distress of their patients are more likely to respond appropr iately to patient cues and will likely have improved outcomes Equally important, it will help shift the standard of how Level I trauma centers provide care and educate their staff Furthermore, a focus on improved empathetic care will lead to a greater number of educated and empowered patients Future Directions Simultaneous and related lines of research regarding patients suffering from orthopaedic trauma injuries and their subsequent psychological distress were concurrently collected while this study was completed. These studies included the efficacy of psychological and prosthetic education for patients preparing to undergo a lower extremity amputation and a comparison of psychological distr ess in orthopaedic trauma patients with severe injuries to patients with less severe injuries (e.g. closed and/or nonsurgical fractures). There are multiple future directions relevant to this line of research which are worthy of investigation and further exploration. Of specific interest is whether the relationship between orthopaedic trauma injuries and psychological distress is multi directional. Put differently, do individuals suffering from anxiety, depression and other psychological issues suffer an increased number of orthopaedic trauma injuries when compared to the general population? The clinical application of these findings would be worthy of note, as those in the fields of psychology and psychiatry concur that the motor system and mood are l inked.15 Construct s such as motor tension are established

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54 diagnostic criteria for assessing affective disorders including general anxiety disorder Indeed, understanding motor deficits brought on by varying levels of psychological distress might be of paramount importanc e, as deficiencies altering movement quality may lead to subsequent movement errors, which may cause additional orthopaedic trauma injuries. Additional work delineating the factors that ameliorate psychological distress should also be examined. It stands to reason that variables analogous to social support, such as belief systems, may ameliorate psychological distress, as well as playing a key role in the functional recovery of patients suffering orthopaedic trauma injuries. Until additional studies are conducted determining if faith and/or belief are mediating variable, anecdotal evidence must be considered compelling, as patients in the current study frequently self reported that their faith or belief served as a support system and coping mec hanism. In addition, finding cost effective solutions that alleviate psychological distress for orthopaedic trauma patients such as meditation and stage appropriate exercise appear promising. An added benefit being that it helps lessen the financial burd en for patients that are lacking resources. Finally, quantifying the psychological distress of trauma care providers may result in tangible benefits to their patients, as providers are frequently subjected to repeated bouts of stress and strain. Without question, empathetic and optimal care is not possible without a healthy and functional orthopaedic trauma team.

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55 APPENDIX A INFORMED CONSENT FORM

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66 LIST OF REFERENCES 1. Brandt EN, C ommittee on Assessing Rehabilitation Science and Engineering, Institute of Medicine. Enabling America Assessing the Role of Rehabilitation Science and Engineering. Washington: National Academies Press; 1997. Available at: http://UH7QF6FD4H.search.serialssolutions.com/?V=1.0&L=UH7QF6FD4H&S=JCs&C =TC0000560465&T=marc&tab=BOOKS. Accessed May 11, 2013. 2. Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation 1994;90(5):2225 2229. 3. Shen B J, Avivi YE, Todaro JF, et al. Anxiety characteristics independently and prospectively predict myocardial infarction in men the unique contribution of anxiety among psychologic factors. J Am Coll Cardiol. 2008;51(2):113 119. doi:10.1016/j.jacc.2007.09.033. 4. CDC Burden of Mental Illness Mental Illness Mental Health Basics Mental Health. Available at: http://www.cdc.gov/mentalhealth/basics/burden.htm. Accessed May 21, 2013. 5. NIMH The Numbers Count: Mental Disorders in America. A vailable at: http://www.nimh.nih.gov/health/publications/thenumbers count mental disorders in america/index.shtml#Intro. Accessed May 21, 2013. 6. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12month DSM IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617 627. doi:10.1001/archpsyc.62.6.617. 7. Lecrubier Y. The burden of depression and anxiety in general medicine. J Clin Psychiatry. 2001;62(8):4 11. 8. Gre enberg PE, Sisitsky T, Kessler RC, et al. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry 1999;60(7):427 435. 9. National hospital discharge survey: 2007 summary Atlanta, GA: Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS); 2007. Available at: http://www.cdc.gov/injury/wisqars. 10. McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A. Psychological distress associated with severe lower limb injury. J Bone Joint Surg Am 2003;85 A(9):1689 1697. 11. Ponsford J, Hill B, Karamitsios M, Bahar Fuchs A. Factors influencing outcome after orthopedic trauma. J Trauma. 2008;64(4):1001 1009. doi:10.1097/TA.0b013e31809fec16.

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67 12. Crichlow RJ, Andres PL, Morrison SM, Haley SM, Vrahas MS. Depression in Orthopaedic Trauma PatientsPrevalence and Severity. J Bone Jt Surg. 2006;88(9):1927 1933. doi:10.2106/JBJS.D.02604. 13. Soberg HL, Bautz Holter E, Roise O, Finset A. Long term multidimensional functional consequences of severe multiple injur ies two years after trauma: a prospective longitudinal cohort study. J Trauma. 2007;62(2):461 470. doi:10.1097/01.ta.0000222916.30253.ea. 14. Starr AJ. Fracture Repair: Successful Advances, Persistent Problems, and the Psychological Burden of Trauma. J Bo ne Jt Surg. 2008;90(Supplement_1):132 137. doi:10.2106/JBJS.G.01217. 15. American Psychiatric Association, American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM IV TR 4th ed., text revision. Washington, DC: American Psychiatric Association; 2000. 16. Beck A, Steer R, Brown G. Manual for Beck Depression Inventory II San Antonio, TX: Psychological Corporation; 1996b. 17. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire2: validity of a twoitem depression screener. Med Care. 2003;41(11):1284 1292. doi:10.1097/01.MLR.0000093487.78664.3C. 18. Spielberger C. Manual for the State Trait Anxiety Inventory Palo Alto, CA: Consulting Psychologists Press; 1983. 19. Watson D, Clark LA. Development and Validation of Brief Measures of Positive and Negative Affect: The PANAS Scales. J Pers Soc Psychol 1988;54(6):1063 1070. 20. Zimet G, Dahlem N, Zimet S, Farley G. The Multidimensional Scale of Perceived Social Support. J Pers Assess. 1988;52(1):30 41. 21. Robinson LR, ed. Trauma rehabilitation. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. 22. Cole TM, Kewman D, Boninger ML. Development of medical rehabilitation research in 20thcentury America. Am J Phys Med Rehabil Assoc Acad Physiatr 2005;84( 12):940 954. 23. McClelland P, Hepburn B, Warres N. Psychological management of the critically ill. In: Cowley A, Conn A, Dunham M, eds. Trauma Care, Medical Management .Vol II. Philadelphia: Lippincott Williams & Wilkins; 1987:198 215. 24. Nagi SZ. A stu dy in the evaluation of disability and rehabilitation potential: concepts, methods, and procedures. Am J Public Health Nations Health 1964;54(9):1568 1579.

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68 25. Nagi S. Some conceptual issues in disability and rehabilitation. In: Sussman M, ed. Sociology and Rehabilitation Washington DC; 1965:100 113. 26. Jette AM. Toward a common language for function, disability, and health. Phys Ther 2006;86(5):726 734. 27. Mattisson E. Psychological aspects of severe physical injury and its treatment. J Trauma. 1974;15:217 234. 28. Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents. BMJ 1993;307(6905):647. 29. Vingilis E, Larkin E, Stoduto G, ParkinsonHeyes A, McLellan B. Psychosocial sequelae of motor vehicle collisions: A follow up study. Accid Anal Prev 1996;28(5):637 645. doi:10.1016/00014575(96)00036X. 30. Gustafsson M, Windahl J, Blomberg K. Ten years follow up of traumarelated psychological distress in a cohort of patients with acute traumatic hand injury. Int J Orthop Tra uma Nurs 2012;16(3):128 135. doi:10.1016/j.ijotn.2012.03.006. 31. Kasai Y, Wang Z, Sakakibara T. Characteristic personality in orthopaedic outpatients. Eur J Orthop Surg Traumatol 2012;22(4):265 268. doi:10.1007/s0059001209636. 32. Gong HS, Lee JO, Huh JK, Oh JH, Kim SH, Baek GH. Comparison of depressive symptoms during the early recovery period in patients with a distal radius fracture treated by volar plating and cast immobilisation. Injury 2011;42(11):1266 1270. doi:10.1016/j.injury.2011.01.005. 33. Wood RL, Maclean L, Pallister I. Psychological factors contributing to perceptions pain intensity after acute orthopaedic injury. Injury 2011;42(11):1214 1218. doi:10.1016/j.injury.2010.07.245. 34. Holbrook TL, Hoyt DB. The impact of major trauma: q uality of life outcomes are worse in women than in men, independent of mechanism and injury severity. J Trauma. 2004;56(2):284 290. doi:10.1097/01.TA.0000109758.75406.F8. 35. Littleton H, Horsley S, John S, Nelson DV. Trauma coping strategies and psychological distress: A meta analysis. J Trauma Stress 2007;20(6):977 988. doi:10.1002/jts.20276. 36. Snyder CR, Pulvers K. Dr. Seuss, the coping machine, and Oh the places youll go. In: Oxford: Oxford University Press; 2001:3 29. 37. Dheensa S, Thomas S. Investigating the relationship between coping, quality of life and depression/anxiety in patients with external fixation devices. Int J Orthop Trauma Nurs 2012;16(1):30 38. doi:10.1016/j.ijotn.2011.06.003.

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69 38. Narrow WE, Regier DA, Norquist G, Rae DS, Kennedy C, Arons B. Mental health service use by Americans with severe mental illnesses. Soc Psychiatry Psychiatr Epidemiol 2000;35(4) :147 155. doi:10.1007/s001270050197. 39. Ponzer S, Bergman B, Brismar B, Johansson LM. A study of patient related characteristics and outcome after moderate injury. Injury 1996;27(8):549 555. 40. Erdfelder E, Faul F, Buchner A. GPOWER: A general power analysis program. Behav Res Methods Instruments Comput 1996;28:1 11. 41. Cohen J. Statistical power analysis for the behavioral sciences 2nd ed. Hillsdale, N.J: L. Erlbaum Associates; 1988. 42. Blader JC. Acute inpatient care for psychiatric disorders i n the united states, 1996 through 2007. Arch Gen Psychiatry. 2011;68(12):1276 1283. doi:10.1001/archgenpsychiatry.2011.84. 43. Kessler RC BP. Lifetime prevalence and ageof onset distributions of DSM IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62(6):593 602. doi:10.1001/archpsyc.62.6.593. 44. Population Division, US Census Bureau DID. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Ag e Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC EST2004 02). 2005. Available at: http://www.census.gov/popest/data/historical/2000s/vintage_2005/index.html. Accessed May 21, 2013. 45. Barnes R, Coombes S, Armstrong N, Higgins T, Janelle C. Evaluating attentional and affective changes following an acute exercise bout using a modified dot probe protocol. J Sports Sci 2010;28(10):1065 1076. 46. Dozois D, Dobson K, Ahnberg J. A psychometric evaluation of the Beck Depression Inventory II. Psychol Assess. 1998;10(2):83 89. 47. Gong HS, Huh JK, Lee JH, Kim MB, Chung MS, Baek GH. Patients Preferred and Retrospectively Perceived Levels of Involvement During DecisionMaking Regarding Carpal Tunnel Release. J Bone Jt Surg. 2011;93(16):1527 1533. doi:10.2106/JBJS.J.00951. 48. Moore L, Lavoie A, Le Sage N, Bergeron E, Emond M, Abdous B. Consensus or dataderived anatomic injury severity scoring? J Trauma. 2008;64(2):420 426. doi:10.1097/01.t a.0000241201.34082.d4.

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70 BIOGRAPHICAL SKETCH Born in 1975, Robert Tarkington Barnes grew up in Long Beach, California. As the son of David and Sherry Barnes, and brother to Alison and Zak, the importance of faith, academics, sports, loyalty and loving English Springer Spaniels were deeply instilled by his parents. After graduating from Los Alamitos High School, he attended Long Beach City College where he played basketball for Hall of Fame coach, Gary Anderson. He left Southern California to earn a B achelor of Arts degree in psychology from California State University, Chico (CSUC). Following the completion of his undergraduate degree, he completed his Master of Arts degree with Distinction in Sport Psychology at CSUC under the mentorship of Dr. Linda Kline. Robert was accepted into the doctoral program at the University of Florida in rehabilitation science under the guidance of Dr. MaryBeth Horodyski. His work with Dr. Horodyski and the Chief of Orthopaedic Trauma Surgery, Dr. Kalia Sadasivan, led to an expertise in understanding the interaction of psychological distress in patients suffering from orthopaedic trauma injuries. While at UF, he married his graduate school sweetheart, Leslie. They have two loyal English Springer Spaniels Miss Juan a nd Mr. Deuce. Robert was awarded his Ph.D. in August 2013.