The psychological impact of traffic injuries sustained in a road crash by bicyclists: A prospective study

Causes and global, regional, and national burdens of traumatic brain injury from 1990 to 2019

PURPOSE

Traumatic brain injury (TBI), currently a major global public health problem, imposes a significant economic burden on society and families. We aimed to quantify and predict the incidence and severity of TBI by analyzing its incidence, prevalence, and years lived with disability (YLDs). The epidemiological changes in TBI from 1990 to 2019 were described and updated to provide a reference for developing prevention, treatment, and incidence-reducing measures for TBI.

METHODS

A secondary analysis was performed on the incidence, prevalence, and YLDs of TBI by sex, age group, and region (n = 21,204 countries and territories) between 1990 and 2019 using the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. Proportions in the age-standardized incidence rate due to underlying causes of TBI and proportions of minor and moderate or severe TBI were also reported.

RESULTS

In 2019, there were 27.16 million (95% uncertainty intervals (UI): 23.36 - 31.42) new cases of TBI worldwide, with age-standardized incidence and prevalence rates of 346 per 100,000 population (95% UI: 298-401) and 599 per 100,000 population (95% UI: 573-627), respectively. From 1990 to 2019, there were no significant trends in global age-standardized incidence (estimated annual percentage changes: -0.11%, 95% UI: -0.18% - -0.04%) or prevalence (estimated annual percentage changes: 0.01%, 95% UI: -0.04% - 0.06%). TBI caused 7.08 million (95% UI: 5.00 - 9.59) YLDs in 2019, with age-standardized rates of 86.5 per 100,000 population (95% UI: 61.1 - 117.2). In 2019, the countries with higher incidence rates were mainly distributed in Central Europe, Eastern Europe, and Australia. The 2019 global age-standardized incidence rate was higher in males than in females. The 2019 global incidence of moderate and severe TBI was 182.7 per 100,000 population, accounting for 52.8% of all TBI, with falls and road traffic injuries being the main causes in most regions.

CONCLUSIONS

The incidence of moderate and severe TBI was slightly higher in 2019, and TBI still accounts for a significant portion of the global injury burden. The likelihood of moderate to severe TBI and the trend of major injury under each injury cause from 1990 to 2019 and the characteristics of injury mechanisms in each age group are presented, providing a basis for further research on injury causes in each age group and the future establishment of corresponding policies and protective measures.

Health literacy and recovery following a non-catastrophic road traffic injury

Background

Health literacy (HL) is rarely addressed in rehabilitation research and practice but can play a substantial role in the recovery process after an injury. We aimed to identify factors associated with low HL and its relationship with 6-month health outcomes in individuals recovering from a non-catastrophic road traffic injury.

Methods

Four hundred ninety-three participants aged ≥17 years who had sustained a non-catastrophic injury in a land-transport crash, underwent a telephone-administered questionnaire. Information was obtained on socio-economic, pre-injury health and crash-related characteristics, and health outcomes (quality of life, pain related measures and psychological indices). Low HL was defined as scoring < 4 on either of the two scales of the Health Literacy Questionnaire that covered: ability to actively engage with healthcare providers (‘Engagement’ scale); and/or understanding health information well enough to know what to do (‘Understanding’ scale).

Results

Of the 493, 16.9 and 18.7% scored < 4 on the ‘Understanding’ and ‘Engagement’ scale (i.e. had low HL), respectively. Factors that were associated with low HL as assessed by both scales were: having pre-injury disability and psychological conditions; lodging a third-party insurance claim; experiencing overwhelming/great perceived sense of danger/death during the crash; type of road user; low levels of social satisfaction; higher pain severity; pain catastrophizing; and psychological- and trauma-related distress. Low HL (assessed by both scales) was associated with poorer recovery outcomes over 6 months. In these longitudinal analyses, the strongest association was with disability (p < 0.0001), and other significant associations were higher levels of catastrophizing (p = 0.01), pain severity (p = 0.04), psychological- (p ≤ 0.02) and trauma-related distress (p = 0.003), lower quality of life (p ≤ 0.03) and physical functioning (p ≤ 0.01).

Conclusions

A wide spectrum of factors including claim status, pre-injury and psychological measures were associated with low HL in injured individuals. Our findings suggest that targeting low HL could help improve recovery outcomes after non-catastrophic injury.

A randomized controlled trial of the influence of yoga for women with symptoms of post-traumatic stress disorder

Background

Survivors in motor vehicle accident (MVA) may have posttraumatic stress disorder (PTSD). Yoga is a complementary approach for PTSD therapy.

Methods

This randomized controlled trial explored whether yoga intervention has effects on reducing the symptoms of PTSD in women survived in MVA. Participants (n = 94) were recruited and randomized into control group or yoga group. Participants attended 6 45-minuite yoga sessions in 12 weeks. Depression Anxiety Stress Scales (DASS) and Impact of Events Scale-Revised (IES-R) were used to assess psychological distress.

Results

Post-intervention IES-R total score of yoga group was significantly lower than that of control group (p = 0.01). At both post-intervention and 3-months post intervention, the DASS-21 total scores of yoga group were both significantly lower than those of control group (p = 0.043, p = 0.024). Yoga group showed lower anxiety and depression level compared to control group at both post-intervention (p = 0.033, p < 0.001) and post-follow-up (p = 0.004, p = 0.035). Yoga group had lower levels of intrusion and avoidance compared to control group after intervention (p = 0.002, p < 0.001).

Conclusion

Results illustrate that yoga intervention may alleviate anxiety and depression and improve the symptoms of PTSD in women with PTSD following MVA.

Fear, Anxiety, and Return to Sport After Cycling Crashes: A Survey of Cyclists

After cycling crashes, orthopedic and neurologic complaints are often the focus of evaluation and management. However, the trauma sustained may not be limited to physical injury; psychological issues brought on by or comorbid with the crash also warrant treatment. In this original research, we evaluated the presence of fear or anxiety after cycling crashes and examined factors associated with this mechanism of injury through a survey. Post-crash fear or anxiety was associated with female gender, a history of depression, and greater crash severity. Few cyclists received treatment and most returned to cycling at their previous level, but the timeline varied.

Comparison of physical and psychological health outcomes for motorcyclists and other road users after land transport crashes: an inception cohort study

BACKGROUND

Serious injuries and fatalities among vulnerable road users on two wheeled motorised vehicles have increased across Australia and internationally in the past decade yet fallen for motor vehicle occupants. Almost half of all reported motorcycle injury crashes cause serious injury or death, nearly double that of motor vehicle police-reported crashes. This study explores associations with sociodemographic and pre-injury health characteristics and health outcomes after a road traffic injury; aiming to compare motorcyclists with other road users and inform recovery care.

METHODS

An inception cohort study recruited 1854 individuals aged > 17 years, injured following land-transport crashes in New South Wales, Australia (July 2013-November 2016). Interviews conducted at baseline, 6-and 12-months post-injury elicited demographic, socioeconomic, and self-reported health conditions.

RESULTS

Primary analysis involved 1854 participants who were recruited at baseline as three distinct road user groups; 628 (33.9%) motorcyclists, 927 (50%) vehicle occupants and 299 (16.1%) bicyclists. At baseline, injury patterns differed significantly between road user groups; motorcyclists were more than twice as likely to sustain lower extremity injury (p < 0.001); to have more severe injury severity scores (p < 0.001) and longer hospital stays versus vs vehicle occupants and bicyclists (< 0.001) across these measures. Injured motorcyclists were predominantly male (88.1%, p < 0.001), were younger on average (38 years) than bicyclists (41.5 years), had lower income and education levels, and poorer pre-injury physical health than other road user groups. Despite these differences, at 12 months post-injury motorcyclists had better physical health (SF12-PCS 2.07 (0.77, 3.36), p = 0.002) and reported lower pain scores (- 0.51 (- 0.83, - 0.2), p < 0.001) than vehicle occupants. Motorcyclists displayed less evidence of psychological distress than vehicle occupants, but more than bicyclists across several measures used.

CONCLUSIONS

Road user types differ in important characteristics, including pre-injury health status and recovery after injury. As vulnerable road users experiencing transport crash and considering their higher initial injury severity, the degree of recovery among motorcyclists compared with other user types is remarkable and unexplained. Health and recovery outcomes after land-transport crashes is least favourable among vehicle occupants despite their higher levels of protection in a crash. This information is valuable for targeting early intervention strategies by road user type during the post-crash care phase, to improve long-term recovery.

The contribution of pre-injury vulnerability to risk of psychiatric morbidity in adults injured in a road traffic crash: Comparisons with non-injury controls

People who sustain injury in a road traffic crash (RTC) have significant risk of psychiatric morbidity, but effective screening for identifying at-risk individuals soon after the RTC is lacking. We investigated whether pre-injury vulnerability can assist as an early screen to manage this risk. We recruited 120 adults who sustained physical injury in a RTC and admitted to an emergency department (ED). They were comprehensively assessed for acute and long-term presence of psychiatric disorder/morbidity and disability over 12-months after the injury, with comparisons to a non-injury control. Propensity matching based on six pre-injury vulnerability factors (age, sex, education, socioeconomic status, prior mental health, prior physical health) with the control group was used to determine membership of high vulnerability (HV) and low vulnerability (LV) injury sub-groups. Compared to the LV sub-group and controls that had similar pre-injury vulnerability, the HV sub-group had a worrying post-RTC recovery profile, with significantly higher rates of long-term psychiatric morbidity (42.2% vs. 23.1% and 15.9% respectively, p = .002) including post-traumatic stress disorder and/or depression, and poorer psychological adjustment over the 12-months. In contrast, the HV and LV sub-groups were similar in injury-related characteristics and post-injury physical (pain, fatigue, physical functioning) and participation outcomes. Findings provide preliminary evidence that pre-injury vulnerability, primarily prior mental health status, is a promising screen for early identification of people at risk of psychiatric morbidity post-RTC. It is suggested this screen could be implemented in ED to prevent chronicity and improve recovery following a traumatic injury. Further research is warranted to enhance the screen's effectiveness.

Different Patterns of Mental Health Outcomes among Road Traffic Crash Survivors: A Prospective Cohort Study

This study aimed to investigate factors associated with the symptoms of mental disorders following a road traffic crash (RTC). A prospective cohort of 200 people was followed for 6 months after experiencing an RTC. The cohort was comprised of uninjured survivors and injured victims with all levels of road traffic injury (RTI) severity. Multivariable logistic regression analyses were performed to evaluate the associations between the symptoms of depression, posttraumatic stress disorder and anxiety one and six months after the RTC, along with sociodemographic factors, health status before and after the RTC, factors related to the RTI and factors related to the RTC. The results showed associations of depression, anxiety, and posttraumatic stress disorder symptoms with sociodemographic factors, factors related to the health status before and after the RTC and factors related to the RTC. Factors related to the RTI showed associations only with depression and posttraumatic stress disorder symptoms. Identifying factors associated with mental disorders following an RTC is essential for establishing screening of vulnerable individuals at risk of poor mental health outcomes after an RTC. All RTC survivors, regardless of their RTI status, should be screened for factors associated with mental disorders in order to successfully prevent them.

Outcomes after traffic injury: mental health comorbidity and relationship with pain interference

BACKGROUND

Mental health symptoms, like depressive mood (DM) and post-traumatic stress (PTS), and pain interference (PI) with daily functioning often co-occur following traffic injury and their comorbidity can complicate recovery. This study aimed to map the course and overlapping trajectories of mental health symptoms, and associations with PI in a traffic injury population.

METHODS

In total, 2019 adults sustaining minor-to-moderate traffic injury were recruited within 28 days post-injury and assessed using phone interviews at 1, 6 and 12-months post-injury. Trajectories of DM, PTS and PI were established and relationships between DM, PTS and PI trajectories were explored using dual trajectory modelling. Bio-psychosocial predictors (e.g. pre-injury health, catastrophizing, acute distress, quality of life, social support) of mental health trajectories were investigated.

RESULTS

Up to five typical post-trauma trajectories were identified for DM, PTS and PI. Most people were in a resilient mental health trajectory (over 60%, DM or PTS), or in a chronic PI trajectory (almost 60%) 12 months post-injury. While recovery/resilient mental health trajectories were strongly interrelated (73.4% joint probability and > 94% conditional probabilities), DM/PTS comorbidity in chronic trajectories was not straightforward, suggesting a possibly asymmetric relationship. That is, persistent DM was more likely associated with persistent PTS (90.4%), than vice versa (31.9%), with a 22.5% probability that persistent PTS was associated with none or milder depression (i.e. following a recovery/resilient DM trajectory). An asymmetrical relationship was also found between mental health and PI. The majority of those with persistent PI were likely to be in a recovery/resilient DM/PTS trajectory (almost 70%), but those in a non-resilient DM/PTS trajectory showed a high risk of persistent PI. Predictors of non-resilient mental health trajectories included poorer pre-injury health and social support, and shared factors like acute psychological distress and pain catastrophizing.

CONCLUSIONS

Strong interrelations were confirmed between mental health symptoms and PI following traffic injury. However, persistent DM was more strongly linked to persistent PTS, than vice versa. Persistent PI was only linked with persistent DM/PTS in vulnerable subgroups. Early psychiatric/psychological interventions should target elevated psychological distress and negative appraisals in vulnerable individuals, to reduce long-term mental health morbidity/comorbidity and PI.

TRIAL REGISTRATION

ACTRN12613000889752.

The impact of acute stress disorder on gallbladder interstitial cells of Cajal

Physical and psychological stress exerts a substantial effect on gastrointestinal motility disorders, where trauma enhances symptoms of digestive dysfunction. Interstitial cells of Cajal (ICCs) act as pacemakers for gastrointestinal motility regulation and are likely important in stress-associated gastrointestinal motility disorders. This study explored the mechanisms underlying gallbladder ICCs function under acute stress conditions using a rabbit chest puncture and cholecystectomy model. The stem cell factor (SCF)/c-kit pathway is essential for the development of ICCs, and gene expression was investigated to identify stress-induced transcriptional alterations. Immunohistochemistry, terminal deoxynucleotidyl transferase dUTP nick end labeling assays were used to determine ICCs apoptosis, whereas western blot analysis and reverse-transcription polymerase chain reaction were used to detect changes in the SCF/c-kit signaling pathway. These methods revealed a reduction in ICCs via apoptosis following stress, and ICCs increased over time after stressor removal. Therefore, this study demonstrates the impact of stress on ICCs development and survival and further confirms the link between stress and gastrointestinal motility.

Twelve-month health outcomes for bicyclists and car occupants after a non-catastrophic traffic crash injury

OBJECTIVE

In this inception cohort study, we investigated differences in health outcomes for bicyclists (cyclists) and car occupants (car driver and passengers) at 12months after a non-catastrophic traffic injury. We also aimed to determine the independent predictors of key health outcomes among cyclists.

METHODS

Of the 2019 participants at baseline, 299 were cyclists and 927 were car occupants; 229 cyclists and 489 car occupants were followed up 12months after the injury. A telephone-administered questionnaire was used to obtain information on socio-economic, pre-injury health and injury-related characteristics. The survey also included tools on health outcomes: quality of life (SF-36 and EQ-5D-3L scales), pain severity, general psychological distress, trauma-related distress and pain catastrophizing.

RESULTS

After adjusting for all potential confounders, general psychological distress scores and trauma-related distress scores were 2.05 and 0.60 units lower for cyclists than car occupants (P=0.01 and P<0.0001, respectively) at 12-month follow-up. Cyclists showed greater improvement than car occupants over 12months in mean pain severity ratings and SF-12 physical component summary (PCS) score (both P<0.0001) but had lower mean pain severity and similar PCS scores at baseline. However, cyclists showed less improvement in SF-12 mental component summary (MCS) scores (P=0.03) than car occupants but had higher mean MCS scores at baseline. Pre-injury and baseline quality-of-life scores and pain catastrophizing as well as injury involving the head or face were significant predictors of overall psychological functioning, general psychological distress and trauma-related distress in cyclists at 12months.

CONCLUSIONS

Cyclists demonstrated better recovery than car occupants at 12months after sustaining a traffic crash injury. Prognostic indicators of long-term physical functioning and psychological well-being in cyclists were related to pre-injury and baseline quality of life and pain factors and injury location.

Predictors of Mental Health Outcomes in Road Traffic Accident Survivors

Mental health outcomes of road traffic accidents (RTAs) are always investigated in assessments of those involved. The aim of this study was to investigate the psychological consequences and associated factors in all RTA survivors, irrelevant of their injury status. A cohort of 155 people was assessed one month after experiencing a RTA using self-reported measures for posttraumatic stress disorder (PTSD), depression, and anxiety. Associations between mental health outcomes and sociodemographic factors, pre-RTA health status, injury-related factors, and RTA details were analyzed. RTA survivors reported substantial rates of PTSD (32.3%) and depression (17.4%) symptoms, and low rates of anxiety (5.8%). Symptoms of depression were associated with below-average self-perceived economic status, irreligiousness, medication use, psychiatric medication use, and injury-related factors. PTSD symptoms were associated with female gender, below-average self-perceived economic status, previous psychiatric illness, medication use, psychiatric medication use, not being at fault in the relevant RTA, claiming compensation, and injury-related factors. Anxiety symptoms were associated with previous chronic or psychiatric illness, previous permanent pain, psychiatric medication use, and self-perceived threat to life, but not with sustaining injury. Along with the evaluation and treatment of RTA injuries, health care providers should evaluate the pre-RTA health status of all RTA victims. Psychological support to those at risk may prevent psychological disorders after RTAs.

Psychological distress following a motor vehicle crash: preliminary results of a randomised controlled trial investigating brief psychological interventions

BACKGROUND

The preliminary results of a randomised controlled trial are presented. The aim of the trial is to determine the efficacy, feasibility and acceptability of email-delivered psychological interventions with telephone support, for adults injured in a motor vehicle crash engaged in seeking compensation. The primary intention for this preliminary analysis was to investigate those who were psychologically distressed and to stop the trial midway to evaluate whether the safety endpoints were necessary.

METHODS

The analysis included 90 adult participants randomised to one of three groups, who were assessed at baseline and post-intervention at 3 months. Cognitive behaviour therapy (CBT) or healthy lifestyle interventions were delivered over 10 weeks, involving fortnightly emailed modules plus clinically focussed telephone support, with the aim of reducing psychological distress. An active waiting list of control subjects received non-clinically focussed telephone contact over the same period along with claim-related reading material. Depression Anxiety Stress Scales (DASS) and Impact of Events Scale (Revised) (IES-R) were used to assess psychological distress. Psychiatric interviews were used to diagnose major depressive disorder and post-traumatic stress disorder. Aspects of acceptability and feasibility were also assessed.

RESULTS

For those diagnosed with depression at baseline in the CBT group, psychological distress reduced by around 16%. For those with depression in the healthy lifestyle group, distress increased marginally. For those in the control group with depression, distress also decreased (by 18% according to DASS-21 and 1.2% according to IES-R). For those without depression, significant reductions in distress occurred, regardless of group (P < .05). The results suggest that for those with depression, a healthy lifestyle intervention is contraindicated, necessitating the cessation of recruitment to this intervention. The interventions were reported as acceptable by the majority and the data indicated that the study is feasible.

CONCLUSIONS

CBT with telephone support reduced psychological distress in physically injured people with depression who are engaged in seeking compensation. However, time plus fortnightly telephone contact with claim-related reading material may be sufficient to reduce distress in those who are depressed. For those who were not depressed, time plus telephone support is most likely sufficient enough to assist them to recover. The trial will continue with further recruitment to only the CBT and control groups, over longer follow-up periods.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: Preventing psychological distress following a motor vehicle accident; ACTRN12615000326594 . Registered on 9 April 2015.

Prevalence and psychometric screening for the detection of major depressive disorder and post-traumatic stress disorder in adults injured in a motor vehicle crash who are engaged in compensation

BACKGROUND

Physical injury and psychological disorder following a motor vehicle crash (MVC) is a public health concern. The objective of this research was to determine rates of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) in adults with MVC-related injury engaged in compensation, and to determine the capacity (e.g. sensitivity and specificity) of two psychometric scales for estimating the presence of MDD and PTSD.

METHODS

Participants included 109 adults with MVC-related injury engaged in compensation during 2015 to 2017, in Sydney, Australia. The mean time from MVC to baseline assessment was 11 weeks. Comprehensive assessment was conducted at baseline, and the Depression Anxiety Stress Scales (DASS-21) and the Impact of Event Scale-Revised (IES-R) were administered to determine probable MDD and PTSD. An online psychiatric interview, based on Diagnostic and Statistical Manual for Mental Disorders (DSM-5), was used to diagnose actual MDD and PTSD, acknowledged as gold standard diagnostic criteria. One-way multivariate analyses of variance established criterion validity of the DASS-21 and IES-R, and sensitivity and specificity analyses were conducted to determine the most sensitive cut-off points for detecting probable MDD and PTSD.

RESULTS

Substantial rates of MDD (53.2%) and PTSD (19.3%) were found. The DASS-21 and IES-R were shown to have excellent criterion validity for detecting MDD and PTSD in injured participants. A range of cut-off points were investigated and shown to have acceptable sensitivity and specificity for detecting MDD and PTSD in an injured population engaged in compensation. The preferred cut-off points based on this study are: to detect MDD, a DASS-21 total score of 30 and/or a DASS-21 depression score of 10; to detect PTSD, IES-R scores of 33-40 and/or a DASS-21 anxiety score of 7-8.

CONCLUSIONS

Major psychological disorder is prevalent following a MVC. Results suggest the DASS-21 and IES-R are suitable for use in clinical/compensation settings to detect probable MDD and PTSD soon after a MVC in physically injured people engaged in compensation. These results provide positive direction in the public health arena for improving mental health outcomes.

TRIAL REGISTRATION

Clinical Trials registration number: ANZCTR - ACTRN12615000326594 (9th April 2015).