Prevalence and predictors of return to work in hospitalised trauma patients during the first year after discharge: a prospective cohort study

[Quality of Life and Return to Work Following Rehabilitation - Results of the icfPROreha Study]

BACKGROUND

Not only the severity of an injury, but also bio-psycho-social factors affect health-related quality of life and participation in social life after severe musculoskeletal injuries.

METHODS

Multicentre prospective longitudinal study with follow-up up to 78 weeks after discharge from inpatient trauma rehabilitation. Data were collected using a comprehensive assessment tool. Quality of life was assessed using the EQ-5D-5L, return to work by patients' self-reports and routine data of health insurances. Analyses of the association between quality of life and return to work, change over time in quality of life compared to the general German population and multivariate analyses to predict quality of life were conducted.

RESULT

Of 612 study participants (444 men (72.5%); M=48.5 years; SD 12.0), 502 (82.0%) returned to work 78 weeks after discharge from inpatient rehabilitation. Quality of life improved during rehabilitation treatment from 50.18 to 64.50 (mean of visual analogue scale of EQ-5D-5L) and slightly to 69.38 78 weeks after discharge from inpatient trauma rehabilitation. EQ-5D index was below the values of the general population. In total, 18 factors were selected to predict quality of life 78 weeks after discharge from inpatient trauma rehabilitation. Among others, pain at rest and suspected anxiety disorder at admission had a very strong effect on quality of life. Contextual factors such as therapies after acute care and self-efficacy also had an effect on quality of life 78 weeks after discharge from inpatient rehabilitation.

CONCLUSION

Bio-psycho-social factors affect long-term quality of life of patients with musculoskeletal injuries. Already at the time of discharge from acute treatment and even more at the beginning of inpatient rehabilitation, decisions can be made in order to achieve the best possible quality of life for those affected.

I'll be back - Predictive validity of adults' expectations for recovery after fractures - A longitudinal observational study

PURPOSE

Recovery after fractures due to accidents relates to all aspects of the biopsychosocial model. Therefore, it is difficult for the patients to foresee the consequences of the fractures. This study aimed to examine 1) patients' expectations regarding the impact of the injury on everyday life, 2) predictive validity of their expectations after six months, and 3) factors that predict a return to work.

PATIENTS AND METHODS

Patients were 18-64 years old and hospitalized with simple or compound/multiple fractures due to an accident. During admission, structured interviews were conducted with a questionnaire covering working conditions, expectations regarding recovery, sports, economy, family, household, and return to work. Additionally, mental and physical status were covered with Short Musculoskeletal Function Assessment questionnaire (SMFA) and Short Form 36, and working conditions were uncovered too. After six months, telephonic interviews were conducted with the 164 available patients to elucidate the impact of the fractures on everyday life, their health status, and sick leave. Likelihood ratios, post-test probabilities, and logistic regression analysis were performed to establish if patients' expectations predicted recovery, economy, sports, family, household, and return to work.

RESULTS

Few patients' baseline expectations about everyday life were met. The likelihood ratios were small, and the post-test probabilities for expectations consistent with outcomes were between 18% and 68%, with recovery as the lowest and participation in sports as the highest. In the multivariate analysis, patients' expectations did not predict short-term (less than two months) or long-term sick leave (more than three months). Self-rated health and the bother index of SMFA were significant short-term and long-term predictors for sick leave. Additionally, vitality, pain, and decision latitude at work predicted sick leave of less than two months.

CONCLUSION

A few days after the accident, patients' expectations about everyday life are not associated with outcomes six months later. Likelihood ratios indicate difficulties for the patients in predicting fractures' consequences on various aspects of everyday life. Return to work was associated with self-rated health and the bother index of SMFA. Future research should examine if fracture patients can benefit from comprehensive, individual counseling during admission to set appropriate expectations.

Depression symptoms reducing return to work: a meta-analysis of prospective studies

Objectives. This study was conducted to estimate the risk of return to work for people who experience symptoms of depression based on the pool of prospective data. Methods. All online articles in PubMed and Scopus which were accessible before November 2019 were searched. The odds ratios of each of the studies were pooled together to obtain an overall odds ratio. The pool of studies was with random effects. The analysis was performed based on the depression symptoms scale, type of disease and duration of follow-up. Two other aspects were examined in the analysis, one being the bias in the publication of studies and the other being the level of heterogeneity that was examined. Results. Thirty-five studies were selected for the meta-analysis. The pooled odds ratio indicates that the odds of return to work in people with depressive symptoms is 31% lower than in those without depressive symptoms. The funnel plot shows that there is asymmetry. The Egger test result was significant (p < 0.001) and there is publication bias. Conclusion. Depression symptoms after sick leave due to physical illness is a risk factor for not returning to work.

[Participation Restriction and its Prediction in Victims of Acts of Violence During the Proceedings Under the Victims Compensation Act: A File-Based Exploratory Cohort Study]

After an act of violence, affected individuals not only suffer psychological and physical damage, but also impairment in their professional, social and societal participation. So far, however, no studies have been conducted examining the severity of participation restrictions and prognostically relevant characteristics. Using a category system, sociodemographic information as well as trauma-, crime- and health-specific characteristics of adult victims of acts of violence, whose entitlement to benefits were recognized under the German Victims Compensation Act (OEG), were recorded from files. Based on psychiatric assessments of damage, participation restrictions were also assessed post-hoc based on the International Classification of Functioning, Disability and Health (ICF). The data are extracted from 99 files; 72 of those affected were female. The average age of the victims at the time of the offence was 25 years. 53 were victims of sexual violence, 24 were victims of forms of bodily injury and 45 were victims of other acts of violence. 29 victims experienced more than one type of violence. All had at least one mental disorder with pathological significance. An average of four years passed between the first and second psychiatric assessment. While 85 of those affected stated that they had been employed before the offence, the number of employees dropped to 53 after the offence. The most pronounced participation restriction was found in professional participation. A multiple regression analysis revealed that a higher degree of participation restriction was associated with lack of employment and a stronger negative impact after the crime as well as the victim's familiarity with the perpetrator; but not associated with a mental disorder or a lack of a victim's trustworthy relationships. In future, participation restrictions should regularly be assessed based on the ICF during the psychiatric assessment. The results suggest that particularly benefits for professional participation are to be granted within the framework of the OEG.

The Effect of Written and Video Discharge Instructions After Mild Traumatic Brain Injury on Healthcare Costs and Productivity Costs

OBJECTIVE

To compare healthcare and productivity costs between patients with mild traumatic brain injury (mTBI) who received verbal discharge instructions only and patients who received an additional flyer with or without video instructions.

SETTING

Emergency departments (EDs) of 6 hospitals in the Netherlands.

PARTICIPANTS

In total, 1155 adult patients with mTBI (384 with verbal instructions; 771 with additional flyer with or without video instructions) were included.

DESIGN

Cost study with comparison between usual care and intervention.

METHODS

Medical and productivity costs up to 3 months after presentation at the ED were compared between mTBI patients with usual care and mTBI patients who received the intervention.

RESULTS

Mean medical costs per mTBI patient were slightly higher for the verbal instructions-only cohort (€337 vs €315), whereas mean productivity costs were significantly higher for the flyer/video cohort (€1625 vs €899). Higher productivity costs were associated with higher working age, injury severity, and postconcussion symptoms.

CONCLUSION

This study showed that the implementation of flyer (and video) discharge instructions for patients with mTBI who present at the ED increased reports of postconcussion symptoms and reduced medical costs, whereas productivity costs were found to be higher for the working population in the first 3 months after the sustained head injury.

The impact of major occupational injuries on professional reintegration. A Portuguese medico-legal contribution

Occupational injuries represent an enormous economic impact for victims, respective families, involved institutions and all the community due to professional outcomes. Thus, it is of the utmost importance that medico-legal personal injury assessment and the posterior follow-up of these victims, may allow their concrete damage repair, considering the victims' needs fulfilment and professional reintegration, whenever possible. The main objective of this study is to reflect on the role that legal medicine can play in promoting the professional reintegration of victims of major occupational accidents through the analysis of occupational injuries cases considering the medico-legal examinations performed. A retrospective study was conducted using medico-legal major occupational injuries cases (Partial Permanent Disability ≥40%). Data were collected from two medico-legal assessment moments: (a) personal injury assessment homologated by a labour court 4.8 years on average after occupational injury; (b) medico-legal follow-up for needs and/or Partial Permanent Disability adjustments performed 18.9 years on average after occupational injury. The final sample includes 103 cases. The results showed that in major occupational accidents, permanent long-term outcomes were principally associated with neurological (62.1%) and orthopaedic (52.4%) sequelae. Permanent professional damage parameters assigned by the labour court included Partial Permanent Disability (23.3%), Permanent Absolute Disability for Regular Work (41.7%) and Permanent Absolute Disability for Any Work (35%). Three-dimensional methodology is helpful in predicting Partial Permanent Disability and Permanent Absolute Disability for Any Work. However, three-dimensional methodology did not reveal correlations with Permanent Absolute Disability for Regular Work, and currently 65% of the victims who were considered able to work by the labour court are not professionally active. Thus, these major cases deserve a more detailed medico-legal approach based on concrete information about the professional reality of each victim, especially cases with an eventual Permanent Absolute Disability for Regular Work. Medico-legal Injury Assessment must be based on concrete aspects of the victim's professional reality and not only on permanent disability tables. This calls for an articulation between all institutions working with the victim of occupational injuries and legal medicine to promote recovery and the necessary measures to assure professional rehabilitation.

Systematic Review of the Association Between Trauma Severity and Postinjury Symptoms of Depression

BACKGROUND

Greater symptoms of depression are associated with greater symptom intensity during recovery from musculoskeletal injury. It is not clear that more severe trauma is associated with greater symptoms of depression as one might expect. The goal of this study was to systematically review the existing evidence regarding the association of Injury Severity Score (ISS) with symptoms of depression during recovery from musculoskeletal injury.

METHODS

Two independent reviewers used PubMed and Embase to identify studies that measured both ISS and symptoms of depression. Among the 17 studies satisfying inclusion criteria, 5 studies assessed the correlation of symptoms of depression and ISS on their continuum; 3 studies compared the mean of symptoms of depression for people above and below a specific ISS level; five compared mean ISS above and below a threshold level of symptoms of depression; and four compared dichotomized ISS and dichotomized depression. Four of the 17 evaluated factors associated with symptoms of depression in multivariable analysis.

RESULTS

In bivariate analysis, 12 of 17 studies (71%) found no association between ISS level and symptoms of depression. Three studies found a bivariate association that did not persist in multivariable analysis. Two studies reported slight associations in bivariate analysis, but did not perform multivariable analysis.

CONCLUSIONS

The knowledge that symptoms of depression are common during recovery, in combination with the finding of this review that they have little or no relationship with injury severity, directs clinicians to anticipate and address mental health during recovery from physical trauma of any severity.

A prospective cohort study on the challenge to return to work after hospitalisation in Brazil

After hospital discharge, workers are expected to return to work (RTW). However, the ability to return and any possible limitations after returning are unclear. Will they be able to RTW? Do they face limitations? This is a prospective cohort study with descriptive analysis aimed to investigate the RTW during 1 year following hospital discharge and to identify any limitations faced by the workers. Data collection occurred between February 2017 and July 2018 in an Internal Medicine Unit at a General Hospital. Convenience sampling was used, and participation was voluntary. Participants comprised 170 adults. Participants' RTW and limitations were followed for 1 year after discharge. During hospitalisation, 95.9% of participants planned to RTW. However, only 30% and 34.1% had returned after 1 month and 1 year respectively. Initially, 57.6% did not believe that they would present any limitation after discharge. However, 85.3% experienced restrictions after 1 month, and after 1 year this percentage rose to 88.2%. A correlation was found between young adults and RTW. The presence of limitations increased non-RTW risk. Therefore, it is recommended that the worker role should not be merely replaced by that of a patient, but it deserves attention of the latter in order to RTW activities. The work-return process must focus on understanding, treating and monitoring workers' limitations over time.

Recovery and Quality of Life After Trauma: A 6-Month Follow-Up Study

BACKGROUND

Injuries were the most common cause of hospitalization in Sweden in 2017. There is a lack of knowledge about trauma recovery and its relation to health-related quality of life (HRQoL) after hospitalization due to minor trauma. This study aimed to prospectively evaluate recovery and HRQoL at discharge from hospital and 3 and 6 months after the trauma.

METHODS

This is a secondary analysis of data from a prospective follow-up study. Fifty-seven patients who sustained physical trauma were included. Recovery was measured with postoperative recovery profile and HRQoL 3 and 6 months after discharge. The association between the outcomes was analyzed, as well as the impact of gender, age, Injury Severity Score (ISS), and trauma mechanism using nonparametric statistics.

RESULTS

There was a significant improvement in recovery and HRQoL between discharge and 3 months after the trauma (p < .001) as well as between 3 and 6 months after the trauma (p < .001) except for EQ-5D VAS scale (p = .222). However, only 14 (25%) patients viewed themselves as fully recovered 6 months after the incident. Correlation between recovery and HRQoL increased after discharge and was at its strongest 6 months after the trauma (rs > .071).

CONCLUSION

Trauma mechanism has an impact on recovery but not gender, age, or ISS score. Most patients did not consider themselves fully recovered even at 6 months postinjury, indicating that they require additional support to manage their recovery.

Functional status, pain and return to work of injured motorcyclists involved in a motorcycle crash over one-year post-injury in Vietnam

OBJECTIVE

This study aimed to determine changes in functional status, pain, and return to work/study (RTW/study) over 12 months post-injury in motorcyclists admitted to a large hospital in Ho Chi Minh City (HCMC), Vietnam.

METHODS

A prospective study was undertaken with adult motorcyclists who were injured due to a crash and were admitted to hospital for more than 24 h. Pain and functional status data were collected at baseline (time of injury), and follow-up at 6 and 12 months post-injury. RTW/study was collected at 6 and 12 months post-injury. Multilevel mixed models and multiple logistic regression models were used to determine the changes in outcomes and predictors of outcomes including age, sex, education, Injury Severity Score, length of stay in the hospital and health-related quality of life.

RESULTS

A total of 352 hospitalised motorcyclists were followed-up. The proportion of motorcyclist RTW/study was 60% (n = 165) at 6 months and 82% (n = 210) at 12 months post-injury. After adjusting for covariates, pain scores improved significantly at 6 months (β = -3.31, 95% CI: -3.61, -3.01) and 12 months post-injury (β = -3.62, 95% CI: -3.92, -3.32) compared to baseline. Functional status increased significantly by 2.89 points (95% CI: 2.64, 3.13) at 6 months and by 3.51 points (95% CI: 3.27, 3.75) at 12 months compared to baseline.

CONCLUSIONS

The study found improvements in outcomes over the study period, although there was ongoing disability at 12 months post-injury (18% had not RTW/study). This study provides further evidence on the burden of motorcycle injuries in Vietnam and priorities for research, and further informs treatment and rehabilitation service planning.

Early versus delayed corpectomy in thoracic and lumbar spine trauma. A long-term clinical and radiological retrospective study

AND BACKGROUND DATA

Many authors have demonstrated the necessity of reconstruction of the anterior column in spinal trauma with vertebral body collapse or nonunion. There is no publication comparing the result depending on the time between trauma and anterior reconstruction of the vertebral body.

OBJECTIVE

To compare long-term clinical and radiological results between early and late anterior vertebral body reconstruction with expandable cages in patients with thoracic and lumbar spine trauma.

HYPOTHESIS

An early anterior reconstruction of thoracolumbar fractures provides better clinical and radiological outcomes than a delayed one.

MATERIALS AND METHODS

A retrospective clinical study was carried out with 44 consecutive patients with injuries of the thoracic and lumbar spine treated operatively with combined posterior stabilization and anterior reconstruction with an expandable implant for vertebral body replacement. All patients were evaluated with EOS full-spine radiograph and CT-scan. The mean follow-up was 5.1 years. Clinical result was evaluated with ODI, SF12, VAS back pain, return to work and sport. Radiological result was evaluated with regional kyphosis angle (RKA) evolution, fusion rate and sagittal alignment. In Group A, twenty-nine patients underwent an early anterior reconstruction within 3 weeks after trauma. The indication of vertebral body reconstruction was placed after post-operative CT-scan for a Mc Cormack score≥7. In Group B, fifteen patients underwent a late anterior reconstruction after diagnosis of nonunion by the combination of pain and CT-scan after 1 year.

RESULTS

Clinical scores and scales were significantly better for patients operated early in Group A. Return to work and activities were significantly more important in Group A too. The mean RKA correction with posterior reduction was 9.3°. The secondary anterior approach permit to reduce 2.9° more. At last follow-up, the loss of reduction was 4.3°. There was no significant difference between groups for those results. No difference in fusion rate was observed between groups. There was no significant difference between groups in the sagittal alignment excepted for SVA that was higher for Group B while remaining under a normal value of 50mm.

CONCLUSION

Early anterior vertebral body reconstruction for fractures gives better clinical results than delayed reconstruction for patients with diagnosis of nonunion in patients with thoracic and lumbar spine trauma. Moreover, the shorter the time from trauma to operation, the better the sagittal reduction of kyphosis. The use of expandable titanium cage is a good way to perform and maintain this reduction.

LEVEL OF EVIDENCE

IV, retrospective study.

Caring for people with serious injuries in urban and regional communities: a qualitative investigation of healthcare providers' perceptions

Purpose: To understand the factors that affect the management of people after serious injury in urban and regional settings, beyond hospital discharge from the perspectives of allied health professionals (AHPs).Materials and methods: An exploratory qualitative study of AHPs caring for people with serious injuries post-hospital discharge in urban and regional areas of Victoria, Australia was completed. Twenty-five semi-structured interviews were undertaken with AHPs and thematically analysed.Results: Allied health professionals in urban and regional settings reported the benefits of a multi-disciplinary team to deliver high-quality care. However, a number of barriers to service delivery were identified that impacted on their ability to meet the needs of patients. These included insufficient psychological services, a shortage of available carers and an unmet need for external clinical support in regional areas. Communication between AHPs and other services, and care co-ordination of post-discharge services, was also highlighted as key areas to improve for optimal patient care.Conclusions: Factors that influenced optimal patient management included the availability of psychological and carer services, communication between health professionals and coordination of post-discharge care. The experiences of AHPs can offer practical suggestions to optimise service delivery and post-discharge care for people with serious injuries.Implications for RehabilitationAllied health professionals (AHPs) face a number of challenges in the provision of optimal care to people with serious injuries.Improving the availability of psychological support and attendant carers is needed in regional areas.A designated care coordinator role may assist people with serious injuries transitioning between hospital and home to engage with necessary services and reduce administrative burden for AHPs.Telehealth may provide facilitate improved communication between health professionals and support regional clinicians caring for people with complex injuries.

Employment predictors of exit from work among workers with disabilities: A survival analysis from the household income labour dynamics in Australia survey

Objectives

Across high-income countries, unemployment rates among workers with disabilities are disproportionately high. The aim of this study was to identify characteristics of employment associated with dropping out of work and assess whether these were different for workers with versus without disabilities.

Methods

Using a longitudinal panel study of working Australians (2001 to 2015), the current study estimated Kaplan–Meier curves and Cox proportional hazard regression models to identify predictors of leaving employment, including psychosocial job quality, employment arrangement, and occupational skill level. Effect modification by disability status of the relationship between employment-related factors and exit from the labour market were assessed by including interaction terms and assessing model fit with a likelihood ratio test. Models were adjusted for a range of socio-demographic and health related factors.

Results

Compared to those without disability, those with disability had a greater risk of leaving employment (HR 1.26, 95% CI 1.18 to 1.35, p<0.001). Other predictors of exit from work included low-skilled occupation (HR 1.18, 95% CI 1.07 to 1.29, p = 0.001), being in a job with low psychosocial job quality (HR 1.11, 95% CI 1.03 to 1.19, p = 0.007), and casual, labour hire or fixed-term contract employment (HR 1.58, 95% CI 1.48 to 1.69, p<0.001). There was no effect modification by disability status.

Conclusions

More research is needed to understand the experiences of workers with disabilities who stay in and leave employment.

Population-based analysis of the impact of trauma on longer-term functional outcomes

BACKGROUND

Functional outcome measures are important as most patients survive trauma. The aim of this study was to describe the long-term impact of trauma within a healthcare region from a social perspective.

METHODS

People active in work or education and admitted to hospitals in Central Norway in the interval 1 June 2007 to 31 May 2010 after sustaining trauma were included in the study. Clinical data were linked to Norwegian national registers of cause of death, sickness and disability benefits, employment and education. Primary outcome measures were receipt of medical benefits and time to return to preinjury work level. Secondary outcome measures were mortality within 30 days or during follow-up.

RESULTS

Some 1191 patients were included in the study, of whom 193 (16·2 per cent) were severely injured (Injury Severity Score greater than 15). Five years after injury, the prevalence of medical benefits was 15·6 per cent among workers with minor injuries, 22·3 per cent in those with moderate injuries and 40·5 per cent among workers with severe injuries. The median time after injury until return to work was 1, 4 and 11 months for patients with minor, moderate and severe injuries respectively. Twelve patients died within 30 days and an additional 17 (1·4 per cent) during follow-up.

CONCLUSION

Patients experiencing minor or major trauma received high levels of medical benefits; however, most recovered within the first year and resumed preinjury work activity. Patients with severe trauma were more likely to receive medical benefits and have a delayed return to work. Registration number: NCT02602405 (http://www.clinicaltrials.gov).

Predictors of work participation for Māori 3 months after injury

An important rehabilitation outcome for injured Māori is a timely sustainable return to work. This article identifies the factors influencing working after injury in an attempt to reduce the individual, social, and economic costs. Māori participants in the Prospective Outcomes of Injury Study were interviewed about preinjury and injury-related factors. Among Māori participants, 521 were working for pay prior to injury; 64% were working 3 months postinjury. Factors identified, using modified Poisson regression, that predicted working include financial security (aRR = 1.34, 95% CI [1.12, 1.61]), an injury of low (aRR = 1.76, 95% CI [1.26, 2.44]) or moderate severity (aRR = 1.86, 95% CI [1.34, 2.59]), professional occupations (aRR = 1.22, 95% CI [1.03, 1.44]), and jobs with less repetitive hand movement (aRR = 1.17, 95% CI [1.01, 1.34]). These factors identified warrant attention when planning interventions to enable rehabilitation back to the workplace.

Reduced Quality of Life, Fatigue, and Societal Participation After Polytrauma

Objective:

This cross-sectional study analyzed associations between and determinants for health-related quality of life (HRQoL), fatigue, and societal participation in polytrauma patients.

Summary of background data:

More polytrauma patients survive their injuries, often resulting in long-term disabilities. HRQoL is therefore an important outcome of trauma care. Fatigue and societal participation may be related to HRQoL. Also, their relation to severe injuries has not been studied to date.

Methods:

A total of 283 polytrauma patients (injury severity score ≥ 16) admitted to the Dutch level 1 Trauma Centre West were analyzed. HRQoL was measured by the physical component summary (PCS) and mental component summary (MCS) scores of the SF-36, fatigue by the multidimensional fatigue inventory, and societal participation by the Utrecht scale for evaluation of rehabilitation-participation. Age, sex, comorbidity, injury pattern, injury severity, and time since trauma were analyzed as potential determinants.

Results:

A total of 122 patients (43%) responded after a median follow-up of 15 (range, 10–23) months after polytrauma; 44% reported reduced physical health (PCS &lt; 45) and 47% reported reduced mental health (MCS &lt; 45). HRQoL was highly correlated with all fatigue and participation subscales. Severe head injury was associated with worse mental health. Female patients reported more general and mental fatigue and were less satisfied with their ability to perform daily activities. Patients with pre-existing comorbidity experienced worse physical health, more fatigue, and reduced societal participation.

Conclusions:

One to 2 years after trauma, polytrauma patients report reduced HRQoL, which is associated with more fatigue and reduced societal participation. Trauma rehabilitation strategies should focus on early recognition of reduced HRQoL, fatigue, and societal participation and facilitate early intervention to improve these outcomes.

Incidence, Intensity, and Impact of Pain in Recently Discharged Adult Trauma Patients: An Exploratory Study

The long-term implications of pain following injury are well known; however, the immediate posthospitalization incidence and impact of pain is less understood. Inadequate pain relief during this time can delay return to work, leading to psychological stress and chronic pain. This exploratory study aimed to identify the incidence, intensity, and impact of injury-related pain in recently discharged adult trauma patients. During July to December 2014, 82 recently discharged adult trauma patients completed a questionnaire about their injury-related pain experience approximately 2 weeks posthospital discharge from a Level 1 trauma center. The questionnaire was developed using the Brief Pain Inventory, assessing severity, and impact of pain through a score from 0 to 10. The average age of participants was 52 years, the median Injury Severity Score was 6, and almost all (n = 80, 98%) experienced a blunt injury. The majority of participants reported pain since discharge (n = 80, 98%), with 65 (81%) still experiencing pain on the day of data collection. Normal work was most affected by pain, with an average score of 6.6 of 10, closely followed by effect on general activity (6.1 of 10) and enjoyment of life (5.7 of 10). The highest pain severity was reported by those with injuries from road trauma, with low Injury Severity Scores, who were female, and did not speak English at home. Pain in the recently discharged adult trauma patient is common, intense and interferes with quality of life. Identification of barriers to effective pain management and interventions to address these barriers are required.

A Return-to-Work Prognostic Model for Orthopaedic Trauma Patients (WORRK) Updated for Use at 3, 12 and 24 Months

Purpose Updating the Wallis Occupational Rehabilitation Risk (WORRK) model formula, predicting non-return to work (nRTW) at different time points (3 and 12 months) than in the validation study (2 years). Methods Secondary analysis of two samples was carried out (following orthopaedic trauma), including work status, the first at 3 months (428 patients) and the second at 12 months (431 patients) after discharge from rehabilitation. We used calibration (agreement between predicted probabilities and observed frequencies) and discrimination (area under the receiver operating characteristics curve) to assess performance of the model after fitting it in the new sample, then calculated the probabilities of nRTW based on the coefficients from the 2-year prediction. Finally, the intercepts were updated for both 3- and 12-month prediction models (re-calibration was necessary for the adjustment of these probabilities) and performance re-evaluated. Results Patient characteristics were similar in all samples (mean age 43 in both groups; 86% male at 3 months, 84% male at 12 months). The proportion of nRTW at 3 months was 63.8% and 53.4% at 12 months (50.36% at 2 years). Performance of the original WORRK for both 3- and 12-month prediction showed an AUC of 0.73, while statistically significant miscalibration was found for both time points (p < 0.001). After the updating of the intercept, calibration was improved and did not show significant miscalibration (p = 0.458 and 0.341). The AUC stayed at 0.73. Conclusion The WORRK model was successfully adapted by changing the intercept for 3- and 12-month prediction of nRTW, now available for use in clinical practice.

Continuing Trauma: The Unmet Needs of Trauma Patients in the Postacute Care Setting

Trauma care has traditionally focused on prehospital and hospital settings, yet many injured patients report emotional distress in the postacute care setting, which is known to impair recovery. The objective of this study was to assess postdischarge emotional recovery and communication preferences. An observational cohort of 100 adult patients from our Level 1 Trauma Center was surveyed one to two months postdischarge. Among those employed preinjury, 44 per cent had not returned to work. Nearly half screened positive for emotional issues (posttraumatic stress disorder, depression, and/or psychological distress); of these, only 35 per cent considered getting professional help and only 10 per cent received help. The barrier most cited (58%) was cost; 42 per cent did not know how or where to get help. Most participants responded “no” or “I don't know” when asked if they had received information about coping with negative emotions after injury and how to seek help from a doctor to address these emotions. Two-thirds preferred to receive such information via phone call from a health care provider or by text. Eighty-nine per cent owned a cellphone. Our trauma systems are failing to provide comprehensive care or look at the ultimate outcomes of our patients, yet modern technology could provide needed resources to patients in novel ways.

Psychological morbidity and return to work after injury: multicentre cohort study

BACKGROUND

The benefits of work for physical, psychological, and financial wellbeing are well documented. Return to work (RTW) after unintentional injury is often delayed, and psychological morbidity may contribute to this delay. The impact of psychological morbidity on RTW after a wide range of unintentional injuries in the UK has not been adequately quantified.

AIM

To quantify the role of psychological factors, including anxiety, depression, and post-traumatic distress, on RTW following unintentional injuries.

DESIGN AND SETTING

A longitudinal multicentre prospective study was undertaken in Nottingham, Bristol, Leicester, and Guildford, UK.

METHOD

Participants (n = 273) were 16-69-year-olds admitted to hospital following unintentional injury, who were in paid employment prior to injury. They were surveyed at baseline, then at 1, 2, 4, and 12 months following injury; demographic data were collected along with injury characteristics, psychological morbidity, and RTW status. Associations between demographic, injury and psychological factors, and RTW between 2 and 12 months after injury were quantified using random effects logistic regression.

RESULTS

The odds of RTW between 2 and 12 months after injury reduced as depression scores early in the recovery period (1 month after injury) increased (odds ratio [OR] 0.87, 95% confidence interval [CI] = 0.79 to 0.95) and as length of hospital stay increased (OR 0.91, 95% CI] = 0.86 to 0.96). For those experiencing threatening life events following injury (OR 0.27, 95% CI = 0.10 to 0.72) and with higher scores on the Crisis Support Scale (OR 0.93, 95% CI] = 0.88 to 0.99), the odds of RTW between 2 and 12 months after injury were lower. Multiple imputation analysis found similar results, but those relating to crisis support did not remain statistically significant.

CONCLUSION

Primary care professionals can identify patients at risk of delayed RTW who may benefit from management of psychological morbidity and support to RTW.

The effect of early psychological symptom severity on long-term functional recovery: A secondary analysis of data from a cohort study of minor injury patients

BACKGROUND

The mental health consequences of injuries can interfere with recovery to pre-injury levels of function and long term wellbeing.

OBJECTIVES

The purpose of this study was to explore the relationship between psychological symptoms after minor injury and long-term functional recovery and disability.

DESIGN

This exploratory study uses secondary data derived from a longitudinal cohort study of psychological outcomes after minor injury.

SETTING

Participants were recruited from the Emergency Department of an urban hospital in the United States.

PARTICIPANTS

A cohort of 275 patients was randomly selected from 1100 consecutive emergency department admissions for minor injury. Potential participants were identified as having sustained minor injury by the combination of three standard criteria including: presentation to the emergency department for medical care within 24h of a physical injury, evidence of anatomical injury defined as minor by an injury severity score between 2 and 8 and normal physiology as defined by a triage-Revised Trauma Score of 12. Patients with central nervous system injuries, injury requiring medical care in the past 2 years and/or resulting from domestic violence, and those diagnosed with major depression or psychotic disorders were excluded.

METHODS

Psychological symptom severity was assessed within 2 weeks of injury, and outcome measures for functional limitations and disability were collected at 3, 6 and 12 months. A quasi-least squares approach was used to examine the relationship between psychological symptom scores at intake and work performance and requirement for bed rest in the year after injury.

RESULTS

Adjusting for demographic and injury covariates, depression symptoms at the time of injury predicted (p≤0.05) both poorer work performance and increased number of days in bed due to health in the year after injury. Anxiety symptoms predicted (p≤0.05) bed days at 3, 6, and 12 months and work performance at 3 months.

CONCLUSIONS

Depression and anxiety soon after minor injury may help predict important markers of long-term recovery. With further research, simple assessment tools for psychological symptoms may be useful to screen for patients who are at higher risk for poor long-term recoveries and who may benefit from targeted interventions.

Prediction of occupational disability from psychological and neuropsychological evidence in forensic context

Within the fields of psychiatry, psychology, and neuropsychology, medical examiners are often tasked with providing an opinion about an injured individual's health prognosis and likelihood of returning to work. Traditionally, examiners have conducted such assessments by employing clinical intuition, expert knowledge, and judgment. More recently, however, an accumulation of research on factors predictive of disability has allowed examiners to provide prognostications using specific empirically supported evidence. This paper integrates current evidence for four common clinical issues encountered in forensic assessments-musculoskeletal pain, depression, Posttraumatic Stress Disorder, and traumatic brain injury. It discusses an evidence-informed, cross-diagnostic and multifactorial model of predicting disability that is emerging from the literature synthesis, along with recommendations for best forensic assessment practice.

Recovery of functional capacity in severe trauma victims at one year after injury: association with trauma-related and hospital stay aspects

[Purpose] The aim of this study was to investigate the functional capacity of trauma survivors one year after hospital discharge and to identify associations with trauma- and hospital stay-related aspects in a developing country. [Subjects and Methods] This study included severe trauma patients (Injury Severity Score ≥16; ≥18 years old) who were admitted to an intensive care unit in Sao Paulo, Brazil. Hospital stay data were collected from the patients’ records. Functional capacity was assessed using the Glasgow Outcome Scale and Lawton Instrumental Activities of Daily Living Scale one year after hospital discharge. Patients were asked if they had returned to work/school. [Results] Forty-nine patients completed follow-up. According to the Glasgow Outcome Scale data, most patients had moderate or mild/no dysfunction. The Lawton Instrumental Activities of Daily Living Scale showed that 60–70% of the subjects performed most activities independently. Multiple linear regression of the Glasgow score, Acute Physiology and Chronic Health Disease Classification System II score, length of mechanical ventilation, and hospital length of stay revealed an association between the Lawton Instrumental Activities of Daily Living Scale and hospital length of stay. Overall, 32.6% of the subjects had returned to work/school. [Conclusion] Most severe trauma patients experienced functional recovery, although only one-third had returned to work/school one year after hospital discharge. Hospital length of stay was identified as a significant predictor of functional recovery.

Prognostic indicators of social outcomes in persons who sustained an injury in a road traffic crash

INTRODUCTION

There is a lack of longitudinal studies with adequate sample size and follow-up period which have objectively assessed social outcomes among those with mild or moderate musculoskeletal injury or that are not limited to hospital inpatients. We aimed to address this gap by prospectively assessing the potential predictors of return to pre-injury work and daily activities.

METHODS

Persons with mild/moderate musculoskeletal injuries from a vehicle-related crash were surveyed within the first 3 months after the crash (baseline; n=364), and at 12 (n=284) and 24 months (n=252). Participants self-reported return to work, and whether it was return to full or modified duties at work. Analyses were restricted to 170 participants who reported being in pre-injury paid work and had provided information at either 12 months only or at both 12 and 24 months. Return to usual activities was assessed using the European Quality of Life-5 Dimensions (EQ-5D) scale 'Usual Activities' dimension.

RESULTS

Twenty-four months after injury 82% (n=121) had returned to work. After multivariable adjustment, not being admitted to hospital was associated with 44% higher likelihood of returning to work at 24 months. Not having any pre-injury chronic illness was associated with returning to work after 24 months, multivariable-adjusted risk ratio (RR), 1.21 (95% confidence intervals, CI: 1.02-1.45). Each 1-SD increase in Medical Outcomes Survey Short Form-12 Mental Component Summary (SF-12 MCS) score at baseline was associated with returning to work at 24 months RR 1.13 (95% CI: 1.02-1.25). Younger age, higher SF-12 physical component summary (PCS), and EQ-5D visual analogue scale (VAS) scores were mutually independent predictors of returning to usual activities 24 months later.

CONCLUSION

A range of bio-psychosocial factors, particularly quality of life measures, independently predicted social outcomes including return to work and return to usual daily activities. These determinants could be measured early in the recovery process and be potentially amenable to intervention.

Predicting non return to work after orthopaedic trauma: the Wallis Occupational Rehabilitation RisK (WORRK) model

Background

Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker’s background.

Methods

Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients’ data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests.

Results

At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate.

Conclusions

Non-RTW may be predicted with a simple model constructed with variables independent of the patient’s education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers.

Determinants of limitations in unpaid work after major trauma: a prospective cohort study with 15 months follow-up

OBJECTIVE

To identify determinants of limitations in unpaid work (household work, shopping, caring for children and odd jobs around the house) in patients who had suffered major trauma (ISS≥16) and who were in full-time employment (≥80%) at the time of injury.

DESIGN

Prospective cohort study.

SETTING

University Medical Centre Utrecht, a level 1 trauma centre in the Netherlands.

METHOD

All severely injured (ISS≥16) adult (age≥16) trauma survivors admitted from January 1999 to December 2000 who were full-time employed at time of the injury were invited for follow-up (n=214). Outcome was assessed with the 'Health and Labour Questionnaire' (HLQ) at a mean of 15 months (SD=1.5) after injury. The HLQ was completed by 211 patients.

RESULTS

Response rate was 93%. Logistic regression analyses identified the percentage of permanent impairment (% PI), level of participation (RtW), co-morbidity, lower extremity injury (LEI) and female gender as determinants of limitations in unpaid work. Patients with a post-injury status of part-time or no return to work experienced more limitations in unpaid work than those who returned to full-time employment.

CONCLUSIONS

Resuming paid work after major trauma is not associated with reductions in unpaid activities. To assess the long-term outcome of rehabilitation programmes, we recommend a measure that combines patient's satisfaction in their post-injury jobs with a satisfactory level of activities in their private lives.

Return to work following unintentional injury: a prospective follow-up study

OBJECTIVE

The aim of this study was to predict time off work following unintentional injuries due to accidents leading to hospital admission.

DESIGN

Prospective 6-month follow-up study.

SETTING

Department of Trauma Surgery of a University Hospital.

PARTICIPANTS

Consecutively recruited victims of unintentional injuries (n=221) hospitalised for a minimum of 32 h including two consecutive nights. All the participants were aged 18-65 years and were able to participate in an assessment within 30 days of the accident.

MAIN OUTCOME MEASURES

Interview-assessed number of days off work during the 6 months immediately following the accident.

RESULTS

The patients' subjective appraisals of (1) accident severity and (2) their ability to cope with the resulting injury and its job-related consequences predicted time off work following the accident beyond the impact of the objective severity of their injury and the type of accident involved.

CONCLUSIONS

The patients' subjective appraisals of the accident severity and of their ability to cope with its consequences are highly relevant for return to work after accidents. Extending the findings from previous studies on severely injured and otherwise preselected accident victims, this seems to apply to the whole spectrum of patients hospitalised with unintentional injuries.

Prevalence and predictors of disability 24-months after injury for hospitalised and non-hospitalised participants: results from a longitudinal cohort study in New Zealand

INTRODUCTION

Most studies investigating disability outcomes following injury have examined hospitalised patients. It is not known whether variables associated with disability outcomes are similar for injured people who are not hospitalised.

AIMS

This paper compares the prevalence of disability 24 months after injury for participants in the Prospective Outcomes of Injury Study who were hospitalised and those non-hospitalised, and also seeks to identify pre-injury and injury-related predictors of disability among hospitalised and non-hospitalised participants.

METHODS

Participants, aged 18-64 years, were recruited from an injury claims register managed by New Zealand's no-fault injury compensation insurer after referral by health care professionals. A wide range of pre-injury socio-demographic, health and psychosocial characteristics were collected, as well as injury-related characteristics; outcome is assessed using the WHODAS. Multivariable models estimating relative risks of disability for hospitalised and non-hospitalised participants were developed using Poisson regression methods.

RESULTS

Of 2856 participants, analyses were restricted to 2184 (76%) participants for whom both pre-injury and 24 month WHODAS data were available. Of these, 25% were hospitalised. In both hospitalised and non-hospitalised groups, 13% experience disability (WHODAS≥10) 24 months after injury; higher than pre-injury (5%). Of 28 predictor variables, seven independently placed injured participants in the hospitalised group at increased risk of disability 24 months after injury; eight in the non-hospitalised. Only four predictors (pre-injury disability, two or more pre-injury chronic conditions, pre-injury BMI≥30 and trouble accessing healthcare services) were common to both the hospitalised and non-hospitalised groups. There is some evidence to suggest that among the hospitalised group, Māori have higher risk of disability relative to non-Māori.

CONCLUSIONS

At 24 months considerable disability is borne, equally, by hospitalised and non-hospitalised groups. However, predictors of disability are not necessarily consistent between the hospitalised and non-hospitalised groups, suggesting caution in generalising results from one group to the other.

Work disability after road traffic injury in a mixed population with and without hospitalisation

BACKGROUND

Studies addressing work disability after road traffic injury are generally aimed at seriously injured hospital patients, and less is known about the disability burden associated with injuries not requiring hospitalisation. The aim of this study was to describe the distribution and determinants of work disability outcomes for patients with musculoskeletal and orthopaedic traffic injuries, including those not sufficiently severe to require hospitalisation.

METHODS

Persons injured in road traffic accidents in 2005-2007 claiming compensation via the Transport Accident Commission (Victoria, Australia) were included if they had compensated time off work, and their most serious injury was musculoskeletal or orthopaedic (n=5970). Work disability outcomes were determined from income compensation payments over 17 months following the accident. Logistic regression models were used relating demographic and injury characteristics to work disability.

RESULTS

Of the injuries, 59% required hospitalisation; 15% required hospitalisation of >1 week. Long-term work disability was common with 32% of injuries resulting in work disability ≥6 months after the accident. The duration of work disability increased markedly with length of hospital stay. Those with no hospital stay accounted for 27% of all work disability days; those with ≤7 days in hospital (including no hospital stay) accounted for 71%. Female sex, age ≥35 years and early opioid prescriptions were also risk factors for work disability ≥6 months after the accident.

CONCLUSION

The majority of work disability days were among patients with one week or less in hospital. Because (short) hospitalisation was relatively common after traffic accidents, the relative work disability burden of non-hospitalised injury is not as great as in a mixed injury aetiology population.

Predicting work-related disability and medical cost outcomes: estimating injury severity scores from workers' compensation data

PURPOSE

Acute work-related trauma is a leading cause of death and disability among US workers. The research objectives were to assess: (1) the feasibility of estimating Abbreviated Injury Scale-based injury severity scores (ISS) from ICD-9-CM codes available in workers' compensation (WC) medical billing data, (2) whether ISS predicts work-related disability and medical cost outcomes, (3) whether ISS adds value over other injury severity proxies, and (4) whether the utility of ISS differs for an all-injury sample compared with three specific injury samples (amputations, extremity fractures, traumatic brain injury).

METHODS

ISS was estimated from ICD-9-CM codes using Stata's user-written -icdpic- program for 208,522 compensable nonfatal WC claims for workers injured in Washington State from 1998 to 2008. The Akaike Information Criterion and R(2) were used to compare severity measures. Competing risks survival analysis was used to evaluate work disability outcomes. Adjusted total medical costs were modeled using linear regression.

RESULTS

Work disability and medical costs increased monotonically with injury severity. For a subset of 4,301 claims linked to the Washington State Trauma Registry (WTR), there was moderate agreement between WC-based ISS and WTR-based ISS. Including ISS together with an early hospitalization indicator resulted in the most informative models; however, early hospitalization is a more downstream measure.

CONCLUSIONS

ISS was significantly associated with work disability and medical cost outcomes for work-related injuries. Injury severity should be considered as a potential confounder for occupational injury intervention, program evaluation, or outcome studies, and can be estimated using existing software when ICD-9-CM codes are available.

Self perceptions as predictors for return to work 2 years after rehabilitation in orthopedic trauma inpatients

PURPOSE

This study aimed to identify self-perception variables which may predict return to work (RTW) in orthopedic trauma patients 2 years after rehabilitation.

METHODS

A prospective cohort investigated 1,207 orthopedic trauma inpatients, hospitalised in rehabilitation, clinics at admission, discharge, and 2 years after discharge. Information on potential predictors was obtained from self administered questionnaires. Multiple logistic regression models were applied.

RESULTS

In the final model, a higher likelihood of RTW was predicted by: better general health and lower pain at admission; health and pain improvements during hospitalisation; lower impact of event (IES-R) avoidance behaviour score; higher IES-R hyperarousal score, higher SF-36 mental score and low perceived severity of the injury.

CONCLUSION

RTW is not only predicted by perceived health, pain and severity of the accident at the beginning of a rehabilitation program, but also by the changes in pain and health perceptions observed during hospitalisation.

Socio-economic outcome after blunt orthopaedic trauma: Implications on injury prevention

Background

Several large studies have identified factors associated with long-term outcome after orthopaedic injuries. However, long-term social and economic implications have not been published so far. The aim of this investigation is to study the long-term socio-economic consequences of patients sustaining severe trauma.

Methods

Patients treated at a level one trauma center were invited for a follow-up (at least 10 years) examination. There were 637 patients who responded and were examined. Inclusion criteria included injury severity score (ISS) ≥ 16 points, presence of lower and upper extremity fractures, and age between 3 and 60 years. Exclusion criteria included the presence of amputations and paraplegia. The socio-economic outcome was evaluated in three age groups: group I (< 18 years), group II (19 - 50 years), and group III (> 50 years). The following parameters were analyzed using a standardized questionnaire: financial losses, net income losses, pension precaution losses, need for a bank loan, and the decrease in number of friends.

Results

510 patients matched all study criteria, and breakdown of groups were as follows: 140 patients in group I, 341 patients in group II, and 29 patients in group III. Financial losses were reported in all age groups (20%-44%). Younger patients (group I) were associated with less income losses when compared with other groups (p < 0.05). Financial deterioration was more frequently reported in age group II (p < 0.05). Social consequences (number of friends decreased) were predominantly stated in patients younger than 18 years old (p < 0.05).

Conclusions

Economic consequences are reported by polytraumatized patients even ten or more years after injury. Financial losses appear to be common in patients between 19 and 50 years. In contrast, social deprivation appears to be most pronounced in the younger age groups. Early socio-economic support and measures of injury prevention should focus on these specific age groups.