Chronic Pain Following Motor Vehicle Collision: A Systematic Review of Outcomes Associated With Seeking or Receiving Compensation

Factors influencing recovery following non-catastrophic injury in a motor vehicle accident: client perspectives

PURPOSE

Injuries sustained in motor vehicle accidents (MVAs) can result in persistent impairments which contribute to decreased quality of life, chronic pain, and increased rates of mental health symptoms. A more explicit understanding of the factors influencing recovery from the perspective of injured persons is needed to inform clinical decision making and rehabilitation service delivery in the Canadian context. This study addressed the following research question: From the perspective of injured persons, what factors are identified as influencing recovery following a non-catastrophic injury sustained in an MVA?

METHODS

This study employed a qualitative interpretive descriptive study design. Data was collected through semi-structured interviews with five occupational therapy clients with non-catastrophic injuries receiving auto insurer funded occupational therapy post-MVA. Constant comparative analysis was used for analysis of interview transcripts.

RESULTS

Prominent factors identified as influencing recovery post-MVA included accepting a new version of self, poor mental health, social support, navigating the insurance system, and access to healthcare.

CONCLUSION

Findings from this study emphasize that recovery from an MVA must be understood within the context of the insurance system, adding to previous research which suggests that claim-related factors impact recovery following an MVA.

Evaluation of the Acceptability and Feasibility of Stress Mitigation Education and Support Delivered via Telehealth for People After Road Traffic Musculoskeletal/Orthopedic Injury

PURPOSE

To evaluate the acceptability and feasibility of a consumer co-designed telehealth intervention which aimed to reduce claimant distress by providing pain management strategies, informational and social support to people who had made a compensation claim following road traffic musculoskeletal injury.

METHODS

Eleven claimant participants who were at risk of a poor outcome completed the intervention in a one-on-one setting with the same clinician delivering the program across all sessions.They were interviewed about their experience (acceptability and feasibility including the use of telehealth). Clinicians who delivered the intervention also completed an anonymous feedback survey exploring their experiences delivering the intervention. Interviews were transcribed verbatim and thematic analysis was conducted.

RESULTS

There were four themes which broadly related to the acceptability and feasibility of the intervention as well as the perceived benefits: (1) knowledge is power, (2) healing with social connection, (3) further along than I would have been, and (4) telehealth was acceptable and feasible.

CONCLUSION

The delivery of a co-designed telehealth-delivered stress mitigation intervention to support people with a road traffic musculoskeletal injury was feasible to deliver and acceptable to people who were at risk of a poor outcome. Further research to evaluate the efficacy of the intervention on outcomes such as pain, self-efficacy, and claims costs are needed.

Do Acute Illness Perceptions Moderate the Association of Pre-Collision Welfare Benefits and Later Neck Pain or Disability Following Whiplash Trauma? A Prospective Multicentre Cohort Study

Objectives: Whiplash trauma is a worldwide significant public health issue, with post-collision chronic pain and physical and mental disability; the prevalence of whiplash trauma in the Japanese general population is estimated at 1.2% and in the Danish general population the whiplash condition has been reported to be 2.9%. Pre-collision welfare benefits and illness perceptions have been found to predict poor recovery after whiplash trauma. In this study, we examined whether illness perceptions measured shortly post-collision moderated the effect of welfare benefits five years before the collision on neck pain and neck-related disability one-year post-collision. Methods: Patients consulting emergency rooms or general practices with neck pain after acute whiplash trauma were invited to complete questionnaires during the week after the collision and at three and 12-months post-collision. Further, we obtained register data on the number of weeks on three types of welfare benefits (sick leave benefits, unemployment benefits, and social assistance benefits) for a five-year period before the collision. Multiple logistic regression was applied. Results: 740 patients were included. We did not find a significant moderating effect of illness perceptions on the association between pre-collision welfare benefits and chronic neck pain and related disability. However, there was a trend towards illness perceptions at baseline and at the three-month follow-up having a moderating effect on the relationship between long-term sick leave and neck pain one year after the whiplash collision. Conclusions: Regarding long-term sick leave, we might have overlooked a substantial moderating effect due to methodological matters and recommend a replication of this study on a larger sample, also focusing on other recovery outcomes.

Psychosocial impacts of post-disaster compensation processes: narrative systematic review

After disasters, many people seek compensation for physical, psychological or economic damages. However, compensation processes can be perceived as arduous and unfair and potentially create stress for both individuals and communities. This systematic review explored the psychosocial impacts of post-disaster compensation processes, including compensation sought through both litigation and government assistance programmes. We searched seven databases, hand-searched reference lists of included studies, and used thematic analysis to synthesise results of included studies. We screened 6,532 papers, ultimately including 66 in the review. While we found mixed evidence regarding the relationship between individual mental health and the compensation process, many studies suggested the process placed demands on emotional resources and could cause stress. Numerous challenges of the compensation process were described, including complicated paperwork, lengthy processes, inadequate information, confusing eligibility criteria, lack of inter-agency cooperation, poor understanding of communities' unique needs, insufficient pay-outs, and politicisation of the process. Inequities in compensation distribution introduced additional stress to already traumatised communities, who often experienced resentment, envy and conflict. The mixed nature of the relationship between mental health and the compensation process was evident in research trends where a small number of studies reported positive findings related to relating to gratitude, helpfulness of compensation and strengthened community relationships, while a substantial number of others reported negative impacts including higher mental health problems. Positive and negative impacts were reported for both litigation and non-litigation compensation-seeking. The nuanced dynamics of these findings are described in greater detail within the paper. It is important that compensation regulators consider the potential impacts on individuals and communities and take steps to address compensation inequities. This enhanced understanding of how those affected by disasters can rebuild their lives and furthering understanding of how to support them will enable evidence-based approaches to building resilience and planning for long-term recovery. Significant compensation process improvements could be realised by ensuring clear communication and transparent decision-making. Overall, this review underscores the importance of ensuring that compensation processes are fair and straightforward so they can repair material losses without deteriorating the social norms and relationships of affected communities.

Predictors of 2-Year Trajectory of Post-Traumatic Stress Disorder Following Physical Injury

Objectives

This study investigated post-traumatic stress disorder (PTSD) trajectories and their predictors over a 2-year period, in individuals recovering from physical injuries.

Materials and Methods

Between June 2015 and January 2021, 1,142 patients from a South Korean University Hospital Trauma Center underwent baseline evaluations, including PTSD-related measures and sociodemographic characteristics. They were subsequently followed up for PTSD using the Clinician-Administered PTSD Scale at 3, 6, 12, and 24 months. The analyzed sample consisted of 1,014 patients who were followed up at least once after the baseline and 3-month evaluations. Latent class growth analysis and logistic regression models were used.

Results

Five distinctive trajectories were identified: resilient, worsening/recovery, worsening, recovery, and chronic groups. The worsening/recovery trajectory was associated with previous traumatic events and traffic-related injuries, while the worsening trajectory was linked to higher education and elevated depressive symptoms. The recovery trajectory was characterized by female sex, childhood abuse, traffic-related injuries, dissociative subtype, and higher levels of anxiety and depressive symptoms. The chronic trajectory was predicted by the dissociative subtype and heightened anxiety symptoms.

Conclusion

These findings highlighted the heterogeneity of PTSD symptom development and, thus, the importance of considering individual characteristics when assessing and addressing PTSD following physical injuries.

Spinal injury rates and specific causation in motor vehicle collisions

Motor vehicle collisions (MVCs) are a leading cause of acute spinal injuries. Chronic spinal pathologies are common in the population. Thus, determining the incidence of different types of spinal injuries due to MVCs and understanding biomechanical mechanism of these injuries is important for distinguishing acute injuries from chronic degenerative disease. This paper describes methods for determining causation of spinal pathologies from MVCs based on rates of injury and analysis of the biomechanics require to produce these injuries. Rates of spinal injuries in MVCs were determined using two distinct methodologies and interpreted using a focused review of salient biomechanical literature. One methodology used incidence data from the Nationwide Emergency Department Sample and exposure data from the Crash Report Sample System supplemented with a telephone survey to estimate total national exposure to MVC. The other used incidence and exposure data from the Crash Investigation Sampling System. Linking the clinical and biomechanical findings yielded several conclusions. First, spinal injuries caused by an MVC are relatively rare (511 injured occupants per 10,000 exposed to an MVC), which is consistent with the biomechanical forces required to generate injury. Second, spinal injury rates increase as impact severity increases, and fractures are more common in higher-severity exposures. Third, the rate of sprain/strain in the cervical spine is greater than in the lumbar spine. Fourth, spinal disc injuries are extremely rare in MVCs (0.01 occupants per 10,000 exposed) and typically occur with concomitant trauma, which is consistent with the biomechanical findings 1) that disc herniations are fatigue injuries caused by cyclic loading, 2) the disc is almost never the first structure to be injured in impact loading unless it is highly flexed and compressed, and 3) that most crashes involve predominantly tensile loading in the spine, which does not cause isolated disc herniations. These biomechanical findings illustrate that determining causation when an MVC occupant presents with disc pathology must be based on the specifics of that presentation and the crash circumstances and, more broadly, that any causation determination must be informed by competent biomechanical analysis.

Pain and mental health symptom patterns and treatment trajectories following road trauma: a registry-based cohort study

PURPOSE

This study aimed to characterise recovery from pain and mental health symptoms, and identify whether treatment use facilitates recovery.

METHODS

Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry participants without neurotrauma who had transport injury claims with the Transport Accident Commission from 2007 to 2014 were included (n = 5908). Latent transition analysis of pain Numeric Rating Scale, SF-12, and EQ-5D-3L pain and mental health items from 6 to 12 months, and 12 to 24 months post-injury were used to identify symptom transitions.

RESULTS

Four transition groups were identified: transition to low problems by 12-months; transition to low problems at 24-months; stable low problems; and no transition from problems. Group-based trajectory modelling of pain and mental health treatments found three treatment trajectories: low/no treatment, a moderate treatment that declined to low treatment 3-12 months post-injury, and increasing treatment over time. Predictors of pain and mental health recovery transitions, identified using multinomial logistic regression, were primarily found to be non-modifiable socioeconomic and health-related characteristics (e.g., higher education, working pre-injury, and not having comorbidities), and low treatment trajectories.

CONCLUSIONS

Targeted and collaborative rehabilitation should be considered for people at risk of persistent pain or mental health symptoms to optimise their recovery, particularly patients with socioeconomic disadvantage.IMPLICATIONS FOR REHABILITATIONTwo-thirds of people experience pain and/or mental health within the first 24-months after hospitalization for road trauma, of whom only 6-7% recover by 12-months, and a further 6% recover by 24-months post-injury.There were three main trajectories of administrative records of treatments received in the first two years after injury: 76 and 83% had low treatment, 18 and 12% had moderate then declining treatment levels, and 6 and 5% had stable high treatment for pain or mental health, respectively.People who recovered from pain or mental health symptoms generally had lower treatment and higher socioeconomic position, highlighting that coordinated rehabilitation care should be prioritized for people living with socioeconomic disadvantage.

Biopsychosocial sequelae of chronically painful injuries sustained in motor vehicle accidents contributing to non-recovery: A retrospective cohort study

BACKGROUND

Claimants with chronically painful injuries sustained in motor vehicle accidents (MVAs) undergo assessment and management influenced by insurance and medico-legal processes defined by a biomedical paradigm which is discordant with best evidence. We aim to demonstrate the impact of biopsychosocial factors on post-MVA sequelae which contribute to non-recovery.

METHODS

This was a retrospective cohort study of medico-legal documents and reports on 300 consecutive claimants referred to a pain medicine physician over 7 years (2012-2018) for assessment of painful musculoskeletal injuries post-MVA. One hundred data items were extracted from the medico-legal documents and reports for each claimant and entered into an electronic database. Post-MVA sequelae were analysed using chi-square analysis (OR >2) for significant associations with demographic, pre-MVA and post-MVA variables. Factors with significant associations were entered into a logistic regression model to determine significant statistical predictors of post-MVA sequelae contributing to non-recovery.

RESULTS

The claimants were aged 17 to 80 years (mean age 42 years), and approximately half (53%, n=159) were female. The time from MVA to interview averaged 2.5 years. Widespread pain was present in 18% (n=54), and widespread somatosensory signs implying central sensitisation (OR=9.85, p<.001) was the most significant multivariate association. Long-term opiate use post-MVA (32%) was predicted by pre-MVA sleep disturbance (OR=5.08, p=.001), post-MVA major depressive disorder (MDD) (OR=3.02, p=.003) and long-term unemployment (OR=2.22. p=.007). Approximately half (47%, n=142) required post-MVA support from a psychologist or psychiatrist. Post-traumatic stress disorder (PTSD) was diagnosed by a psychiatrist or psychologist in 20% (n=59), yet early identification of risk of PTSD was rare. Pre-MVA, 89.4% (n=268) were studying or employed. Permanent unemployability post-MVA occurred in 35% (n=104) and was predicted by MDD (OR=3.59, p=.001) and antidepressant use (OR=2.17, p=.005). Major social change post-MVA (70%) was predicted by older age (OR=.966, p=.003), depressive symptoms (OR=3.71, p<.001) and opiate use (OR=2.00, p=.039).

CONCLUSIONS

Biomedical factors, including older age, impaired sleep and indicators of widespread central sensitisation, and psychological factors, including stress, anxiety and depression, were the most prominent multivariate associations as statistical predictors of major adverse sequelae contributing to non-recovery for claimants with chronic pain post-MVA.

Factors associated with long term work incapacity following a non-catastrophic road traffic injury: analysis of a two-year prospective cohort study

Background

Road traffic injuries (RTIs), primarily musculoskeletal in nature, are the leading cause of unintentional injury worldwide, incurring significant individual and societal burden. Investigation of a large representative cohort is needed to validate early identifiable predictors of long-term work incapacity post-RTI. Therefore, up until two years post-RTI we aimed to: evaluate absolute occurrence of return-to-work (RTW) and occurrence by injury compensation claimant status; evaluate early factors (e.g., biopsychosocial and injury-related) that influence RTW longitudinally; and identify factors potentially modifiable with intervention (e.g., psychological distress and pain).

Methods

Prospective cohort study of 2019 adult participants, recruited within 28 days of a non-catastrophic RTI, predominantly of mild-to-moderate severity, in New South Wales, Australia. Biopsychosocial, injury, and compensation data were collected via telephone interview within one-month of injury (baseline). Work status was self-reported at baseline, 6-, 12-, and 24-months. Analyses were restricted to participants who reported paid work pre-injury (N = 1533). Type-3 global p-values were used to evaluate explanatory factors for returning to ‘any’ or ‘full duties’ paid work across factor subcategories. Modified Poisson regression modelling was used to evaluate factors associated with RTW with adjustment for potential covariates.

Results

Only ~ 30% of people with RTI returned to full work duties within one-month post-injury, but the majority (76.7%) resumed full duties by 6-months. A significant portion of participants were working with modified duties (~ 10%) or not working at all (~ 10%) at 6-, 12-, and 24-months. Female sex, low education, low income, physically demanding occupations, pre-injury comorbidities, and high injury severity were negatively associated with RTW. Claiming injury compensation in the fault-based scheme operating at the time, and early identified post-injury pain and psychological distress, were key factors negatively associated with RTW up until two years post-injury.

Conclusions

Long-term work incapacity was observed in 20% of people following RTI. Our findings have implications that suggest review of the design of injury compensation schemes and processes, early identification of those at risk of delayed RTW using validated pain and psychological health assessment tools, and improved interventions to address risks, may facilitate sustainable RTW.

Trial registration

This study was registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12613000889752).

Effects of seeking compensation on the psychological health and recovery of injured patients: the role of stress vulnerability and injury-related disability

BACKGROUND

Seeking compensation has been shown to have an adverse effect on the psychological health and recovery of injured patients, however, this effect requires clarification.

METHODS

A total of 2019 adults sustaining a traffic injury were recruited. Of these, 709 (35.1%) lodged a compensation claim. Interviews occurred at 1-, 6- and 12-month post-injury. Outcomes were psychological distress (posttraumatic stress (PTS) and depressive symptoms) and health-related functioning (HrF) (quality of life measured by EQ-5D-3L and disability by WHODAS) over 12-months post-injury. Covariates included individual stress vulnerability (preinjury, injury-related factors).

RESULTS

Compared with non-compensation participants, compensation groups had higher stress vulnerability (more severe injuries and negative reactions) and poorer baseline outcomes (psychological health and HrF). After adjustment, we found an effect of compensation on HrF [β-0.09 (-0.11 to -0.07), p < 0.001] and PTS [β = 0.36 (0.16 to 0.56), p = 0.0003], but not on depression [β = -0.07 (-0.42 to 0.28), p = 0.7]. Both groups improved over time. Vulnerable individuals (β = 1.23, p < 0.001) and those with poorer baseline outcomes (PTS: β = 0.06, p = 0.002; HrF: β = -1.07, p < 0.001) were more likely to lodge a claim. In turn, higher stress vulnerability, poor baseline outcomes and claiming compensation were associated with long-term psychological distress and HrF. Nevertheless, concurrent HrF in the model fully accounted for the compensation effect on psychological distress (β = -0.14, p = 0.27), but not vice versa.

CONCLUSIONS

This study provides convincing evidence that seeking compensation is not necessarily harmful to psychological health. The person's stress vulnerability and injury-related disability emerge as major risk factors of long-term psychological distress, requiring a whole-systems approach to address the problem.

The use of professional help and predictors of unmet needs for dealing with mental health to legal problems among victims of violence, accidents, theft and threat, and nonvictims in the general population

AIMS

Victims of violence, accidents, theft, and serious threat (hereafter abbreviated as victims) are more than nonvictims at risk for problems in different domains, varying from mental health to legal problems. However, the extent to which victims with these problems compared to nonvictims with similar problems receive problem-related professional or formal help is unclear. It is unknown if predictors of unmet needs differ between victims and nonvictims. Aim of the present study is to fill this gap of knowledge.

METHODS

Data was extracted from surveys of the VICTIMS-study (2018, 2019 and 2020), conducted with the Dutch population-based longitudinal LISS panel. Each survey assessed 1.) experiences with physical violence, accidents, theft, and serious threat and other traumatic or stressful events in the past 12 months and 2.) various problems and use of professional help, e.g. do receive help, do not need help, could use help but do not use it, cannot find or afford help for these problems. Multivariate logistic regression analyses were performed to assess differences in problems, in the use of problem-related professional help, and in predictors of unmet needs between victims (N = 1,756) and nonvictims (N = 5,000).

RESULTS

Victims more often had assessed problems than nonvictims. Victims compared to nonvictims with similar problems had 1.5 to 2 times more often unmet needs: they could not find or afford professional help for their mental, physical, partner/family, financial and legal problems. In addition, victims less often received help for legal and administrative problems. Most predictors of unmet needs, e.g. could use help but do not use it, cannot find or afford help, were not significant and hardly differed between both groups.

CONCLUSIONS

The findings that victims compared to nonvictims more often have various problems and more often cannot find or afford problem-related professional help, suggest that there is room for improvement for victims services.

AAAPT Diagnostic Criteria for Acute Low Back Pain with and Without Lower Extremity Pain

OBJECTIVE

Low back pain is one of the most common reasons for which people visit their doctor. Between 12% and 15% of the US population seek care for spine pain each year, with associated costs exceeding $200 billion. Up to 80% of adults will experience acute low back pain at some point in their lives. This staggering prevalence supports the need for increased research to support tailored clinical care of low back pain. This work proposes a multidimensional conceptual taxonomy.

METHODS

A multidisciplinary task force of the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) with clinical and research expertise performed a focused review and analysis, applying the AAAPT five-dimensional framework to acute low back pain.

RESULTS

Application of the AAAPT framework yielded the following: 1) Core Criteria: location, timing, and severity of acute low back pain were defined; 2) Common Features: character and expected trajectories were established in relevant subgroups, and common pain assessment tools were identified; 3) Modulating Factors: biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: domains of impact were outlined and defined; 5) Neurobiological Mechanisms: putative mechanisms were specified including nerve injury, inflammation, peripheral and central sensitization, and affective and social processing of acute low back pain.

CONCLUSIONS

The goal of applying the AAAPT taxonomy to acute low back pain is to improve its assessment through a defined evidence and consensus-driven structure. The criteria proposed will enable more rigorous meta-analyses and promote more generalizable studies of interindividual variation in acute low back pain and its potential underlying mechanisms.

Prognostic Role of Demographic, Injury and Claim Factors in Disabling Pain and Mental Health Conditions 12 Months after Compensable Injury

Identifying who might develop disabling pain or poor mental health after injury is a high priority so that healthcare providers can provide targeted preventive interventions. This retrospective cohort study aimed to identify predictors of disabling pain or probable mental health conditions at 12 months post-injury. Participants were recruited 12-months after admission to a major trauma service for a compensable transport or workplace injury (n = 157). Injury, compensation claim, health services and medication information were obtained from the Victorian Orthopaedic Trauma Outcome Registry, Victorian State Trauma Registry and Compensation Research Database. Participants completed questionnaires about pain, and mental health (anxiety, depression, posttraumatic stress disorder) at 12 months post-injury. One third had disabling pain, one third had at least one probable mental health condition and more than one in five had both disabling pain and a mental health condition at 12 months post-injury. Multivariable logistic regression found mental health treatment 3-6 months post-injury, persistent work disability and opioid use at 6-12 months predicted disabling pain at 12 months post-injury. The presence of opioid use at 3-6 months, work disability and psychotropic medications at 6-12 months predicted a mental health condition at 12 months post-injury. These factors could be used to identify at risk of developing disabling pain who could benefit from timely interventions to better manage both pain and mental health post-injury. Implications for healthcare and compensation system are discussed.

Health and return to work in the first two years following road traffic injury: a comparison of outcomes between compensation claimants in Victoria and New South Wales, Australia

BACKGROUND

People who sustain road traffic injuries often have poor health outcomes. While outcomes are often worse in people with a compensation claim, especially in fault-based schemes versus no-fault schemes, few studies have directly compared outcomes across scheme types.

OBJECTIVE

To compare health and work outcomes between people who had no compensation claim, a fault-based claim, or "no-fault" transport or workers compensation claim after hospitalisation for a road traffic injury.

METHODS

Participants aged >=18 years admitted to hospital in New South Wales or Victoria for >24 hours were recruited in two separate prospective cohort studies (N=1,034). People who died or sustained minor or very severe injuries were excluded. Groups included Compulsory Third Party (fault-based, n=128), no-fault Transport Accident Commission (TAC; n=454) and workers compensation claimants (n=73), or no claim (n=226). Outcomes at six, 12- and 24-months post-injury included health [SF-12 Mental Component Score (MCS) and Physical Component Score (PCS)], and return to work for people working pre-injury. Multivariable mixed effects linear and logistic regressions, adjusting for demographic and injury covariates, examined differences in health and work outcomes between claimant groups, with fixed effects of time and random effects of participant ID.

RESULTS

Health status was better in people with a no-fault TAC claim (MCS: m=50.62, 95%CI:49.62,51.62; PCS: m=40.49, 95%CI:39.46,41.52) or no claim (MCS: m=49.99, 95%CI:49.62,51.62; PCS: m=44.36, 95%CI:43.00,45.72), than people with a workers compensation (MCS: m=45.73, 95%CI:43.46,48.00; PCS: m=38.94, 95%CI:36.59,41.30) or fault-based CTP claim (MCS: m=41.34, 95%CI:39.54,43.13; PCS: m=35.64, 95%CI:33.78,37.49). Relative to fault-based CTP claimants, the odds of returning to work were higher for people with no claim (AOR=6.84, 95%CI:1.73,27.05) but did not differ for no-fault TAC (AOR=1.21, 95%CI:0.36,4.05) or workers compensation claimants (AOR=0.83,95%CI: 0.17,3.99). While people with a fault-based CTP claim had poorer mental and physical health and return to work after injury, they showed greater improvements in mental health, and similar levels of improvement in physical health and work participation over time to the other groups.

CONCLUSION

The patterns of health and work across scheme types provide important insights against which we can contrast the effects of future scheme designs on client outcomes.

A systematic review of the association between fault or blame-related attributions and procedures after transport injury and health and work-related outcomes

Attributions of fault are often associated with worse injury outcomes; however, the consistency and magnitude of these impacts is not known. This review examined the prognostic role of fault on health, mental health, pain and work outcomes after transport injury. A systematic search of five electronic databases (Medline, Embase, CINAHL, PsycINFO, Cochrane Library) yielded 16,324 records published between 2000 and January 2018. Eligibility criteria were: adult transport injury survivors; prospective design; multivariable analysis; fault-related factor analysed; pain, mental health, general health or work-related outcome. Citations (n = 10,558, excluding duplicates) and full text articles (n = 555) were screened manually (Reviewer 1), and using concurrent machine learning and text mining (Reviewer 2; using Abstrackr, WordStat and QDA miner). Data from 55 papers that met all inclusion criteria were extracted, papers were evaluated for risk of bias using the QUIPS tool, and overall level of evidence was assessed using the GRADE tool. There were six main fault-related factors classified as: fault or responsibility, fault-based compensation, lawyer involvement or litigation, blame or guilt, road user or position in vehicle, and impact direction. Overall there were inconsistent associations between fault and transport injury outcomes, and 60% of papers had high risk of bias. There was moderate evidence that fault-based compensation claims were associated with poorer health-related outcomes, and that lawyer involvement was associated with poorer work outcomes beyond 12 months post-injury. However, the evidence of negative associations between fault-based compensation claims and work-related outcomes was limited. Lawyer involvement and fault-based compensation claims were associated with adverse mental health outcomes six months post-injury, but not beyond 12 months. The most consistent associations between fault and negative outcomes were not for fault attributions, per se, but were related to fault-related procedures (e.g., lawyer engagement, fault-based compensation claims).

Pain, Anxiety, and Depression in the First Two Years Following Transport-Related Major Trauma: A Population-Based, Prospective Registry Cohort Study

Objectives

This study aimed to characterize the population prevalence of pain and mental health problems postinjury and to identify risk factors that could improve service delivery to optimize recovery of at-risk patients.

Methods

This population-based registry cohort study included 5,350 adult survivors of transport-related major trauma injuries from the Victorian State Trauma Registry. Outcome profiles were generated separately for pain and mental health outcomes using the “pain or discomfort” and “anxiety or depression” items of the EuroQol Five Dimensions Three-Level questionnaire at six, 12, and 24 months postinjury. Profiles were “resilient” (no problems at every follow-up), “recovered” (problems at six- and/or 12-month follow-up that later resolved), “worsening” (problems at 12 and/or 24 months after no problems at six and/or 12 months), and “persistent” (problems at every follow-up).

Results

Most participants had persistent (pain/discomfort, N = 2,171, 39.7%; anxiety/depression, N = 1,428, 26.2%) and resilient profiles (pain/discomfort, N = 1,220, 22.3%; anxiety/depression, N = 2,055, 37.7%), followed by recovered (pain/discomfort, N = 1,116, 20.4%; anxiety/depression, N = 1,025, 18.8%) and worsening profiles (pain/discomfort, N = 956, 17.5%; anxiety/depression, N = 948, 17.4%). Adjusted multinomial logistic regressions showed increased risk of problems (persistent, worsening, or resolved) vs no problems (resilient) in relation to female sex, middle age, neighborhood disadvantage, pre-injury unemployment, pre-injury disability, and spinal cord injury. People living in rural areas, motorcyclists, pedal cyclists, and people with head, chest, and abdominal injuries had lower risk of problems.

Discussion

Targeted interventions delivered to people with the risk factors identified may help to attenuate the severity and impact of pain and mental health problems after transport injury.

Beyond symptom resolution: insurance case manager's perspective on predicting recovery after motor vehicle crash

PURPOSE

Insurance company case managers can play a critical role in the rehabilitation process of people with musculoskeletal disorders sustained following minor motor vehicle crash injury due to their interaction with multiple stakeholders and their role in approving various services. This study aimed to identify factors that case managers perceive as predictive of recovery in people with musculoskeletal disorders after minor motor vehicle crash injury.

MATERIALS AND METHODS

To explore the perspectives of cases managers in Australia and the United States, semi-structured interviews explored factors that case managers thought provided an early indication of likely recovery outcomes in people with musculoskeletal disorders after minor motor vehicle crash injury. A framework analysis was applied and factors were displayed within the ICF-framework.

RESULTS

Case managers (n = 40) demonstrated a broad, detailed understanding of biopsychosocial and contextual issues influencing recovery. They emphasized the importance of the injured worker's expressed affect and motivation, style of communication, the role of lawyers, the worker's family and friends, as well as cultural and geographic influences. The overarching themes perceived as having a major influence on recovery outcomes were general health, pain processing and response, work situation, and compensation entitlement.

CONCLUSIONS

Case managers' broad and detailed perceptions about recovery may provide additional, valuable perspectives for professionals involved in the rehabilitation process of people with musculoskeletal disorders after minor motor vehicle crash injury. Further research needs to be conducted to explore the effects of case manager involvement in the process of recovery.Implications for rehabilitationInsurance Case Managers identified multiple factors including affect and motivation, style of communication, the role of lawyers, family and friends, cultural and geographic variation provide opportunities for more effective treatment of people with musculoskeletal disorders related to minor motor vehicle collisions. These managers' perceptions about recovery may be informative to and provide opportunities for health professionals involved in the rehabilitation of people with musculoskeletal disorders related to minor motor vehicle collisions.While the Insurance Case Managers involved in this research did not use formalized assessment techniques, tools and assessment protocols could be developed jointly between for the needs of Insurance Case Managers and other stakeholders to tackle recovery of people with musculoskeletal disorders related to minor motor vehicle collision.

Biopsychosocial barriers affecting recovery after a minor transport-related injury: A qualitative study from Victoria

Objective

The aim of the study was to understand the recovery phenomena and to explore participants' perspectives on the biopsychosocial facilitators and barriers affecting their recovery after a minor transport injury.

Methods

A qualitative method was used involving semi‐structured interviews with 23 participants who sustained a minor transport injury. Interviews and analysis were guided by the biopsychosocial model (BPS) of health. The outcomes were themes capturing biopsychosocial barriers to, and personal experiences of, recovery using a previously defined framework.

Results

The themes indicate that recovery is a multifaceted phenomenon affected by comorbidities such as chronic pain, depression and anxiety. A range of subsequent complexities such as the inability to self‐care and undertaking daily domestic duties, and incapacity to participate in recreational activities were major barriers to recovery. These barriers were found to be an on‐going source of frustration, dissatisfaction and a perceived cause of depressive symptomatology in many participants. Most participants reported mixed feelings of the care received. Other common issues raised included a lack of understanding of the assessment time, regular follow‐up, guidance and on‐going support.

Conclusion

This study revealed that recovery after a minor transport‐related injury was a challenging, complex, demanding and a long‐term process for the individuals in this study. Findings from this limited cohort suggested that, for participants to return to their pre‐accident health status, a more coordinated approach to information and care delivery may be required.

Impact of further injury on participation in work and activities among those previously injured: results from a New Zealand prospective cohort study

PURPOSE

To examine participation in paid work, unpaid work and activities 12 months after a sentinel (initial) injury, and to determine the impact of sustaining a subsequent injury (SI) on these participation outcomes.

METHODS

Participants were recruited to the Prospective Outcomes of Injury Study following an Accident Compensation Corporation (ACC; New Zealand's no-fault injury insurer) entitlement claim injury. Outcomes were whether participants reported reduced paid work hours, reduced unpaid work (e.g. housework, gardening) or reduced activities (e.g. socialising, leisure pursuits) at 12 months compared to before the sentinel injury event. SIs were ACC claims of any type. Using multivariable models, characteristics of SIs were examined as potential predictors of reduced participation.

RESULTS

At 12 months, 30% had reduced paid work hours, 12% had reduced unpaid work and 25% had reduced activities. Sustaining a SI predicted reduced paid work (RR 1.5; 95% CI 1.2, 1.8), but not unpaid work or activities. Participants who had sustained intracranial SIs were at highest risk of reduced paid work (RR 3.2, 95% CI 1.9, 5.2). Those sustaining SIs at work were less likely to have reduced paid work (RR 0.7; 95% CI 0.6, 1.0) than those with only non-work SIs. Participants sustaining assaultive SIs had higher risk of reduced unpaid work (RR 2.6, 95% CI 1.0, 6.8).

CONCLUSIONS

Reduced participation is prevalent after a substantive sentinel injury, and sustaining a SI impacts on return to paid work. Identification of SI characteristics that put people at high risk of participation restriction may be useful for focusing on rehabilitative attention.

Biopsychosocial factors associated with non-recovery after a minor transport-related injury: A systematic review

Background

Globally, road transport accidents contribute significantly to mortality and burden of disability. Up to 50 million people suffer a transport-related non-fatal injury each year, which often leads to long-term disability. A substantial number of people with minor injuries struggle to recover and little is known about the factors leading to poor or non-recovery. The aim of this paper is to present a systematic review of biopsychosocial factors related to poor or non-recovery after a minor transport-related injury.

Methods and findings

Studies were selected through searches of PubMed, Medline, Embase, and Cochrane library. Methodological quality was assessed using a Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklist for quantitative cohort studies and Standards for Reporting Qualitative Research (SRQR) checklist for qualitative articles. Data were extracted using the Cochrane data extraction tool based on the biopsychosocial model of health (BPS). In total, there were 37 articles included. However, heterogeneity of the techniques and tools used to assess factors and outcomes across studies meant that pooling of results to determine biopsychosocial factors most predictive of poor or non-recovery was not possible. Hence, a narrative synthesis was conducted and shown multiple factors to be associated with poorer outcomes or non-recovery, most being identified in the biological and psychological domain of the BPS model. Factors that were the most representative across studies and have shown to have the strongest associations with poor or non-recovery were high initial pain intensity, pain duration and severity, pre-accident physical and mental health status and pain catastrophising.

Conclusions

This review demonstrates the complexity of recovery and a challenge in reporting on predictors of recovery. It is evident that a range of multi-factorial biopsychosocial factors impact recovery. These factors are often inter-connected and multi-faceted and therefore, it was not feasible to select or focus on one single factor. In defining the most predictive factors, further research is required, yet the consensus around which tools to use to measure recovery outcomes is needed and is highly recommended. Regardless of the descriptive nature, the review demonstrated that high levels of post-injury pain are associated with poorer outcomes such as chronic pain and physical and mental disability. Therefore, early targeting of modifiable factors such as pain, pain catastrophizing and arising comorbidities such as PTSD, depression and anxiety may assist in reducing chronic pain and ongoing related disabilities.

Systematic review trial registration number

Systematic review protocol was registered in International Prospective Register for Systematic Reviews (PROSPERO) on 14 December 2016. Registration number CRD42016052276.

Associations between compensable injury, perceived fault and pain and disability 1 year after injury: a registry-based Australian cohort study

OBJECTIVES

Compensable injury increases the likelihood of having persistent pain after injury. Three-quarters of patients report chronic pain after traumatic injury, which is disabling for about one-third of patients. It is important to understand why these patients report disabling pain, in order to develop targeted preventative interventions. This study examined the experience of pain and disability, and investigated their sequential interrelationships with, catastrophising, kinesiophobia and self-efficacy 1 year after compensable and non-compensable injury.

DESIGN

Observational registry-based cohort study.

SETTING

Metropolitan Trauma Service in Melbourne, Victoria, Australia.

PARTICIPANTS

Participants were recruited from the Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry. 732 patients were referred to the study, 82 could not be contacted or were ineligible, 217 declined and 433 participated (66.6% response rate).

OUTCOME MEASURES

The Brief Pain Inventory, Glasgow Outcome Scale, EuroQol Five Dimensions questionnaire, Pain Catastrophising Scale, Pain Self-Efficacy Questionnaire, Injustice Experience Questionnaire and the Tampa Scale of Kinesiophobia.

METHODS

Direct and indirect relationships (via psychological appraisals of pain/injury) between baseline characteristics (compensation, fault and injury characteristics) and pain severity, pain interference, health status and disability were examined with ordinal, linear and logistic regression, and mediation analyses.

RESULTS

Injury severity, compensable injury and external fault attribution were consistently associated with moderate-to-severe pain, higher pain interference, poorer health status and moderate-to-severe disability. The association between compensable injury, or external fault attribution, and disability and health outcomes was mediated via pain self-efficacy and perceived injustice.

CONCLUSIONS

Given that the associations between compensable injury, pain and disability was attributable to lower self-efficacy and higher perceptions of injustice, interventions targeting the psychological impacts of pain and injury may be especially necessary to improve long-term injury outcomes.

Biopsychosocial factors associated with non-recovery after a minor transport-related injury: protocol for a systematic review

INTRODUCTION

Globally, road transport accidents contribute substantially to the number of deaths and also to the burden of disability. Up to 50 million people suffer a transport-related non-fatal injury each year, which often leads to long-term disability. It has been shown that substantial number of people with minor injuries struggle to recover and the reasons are still not well explored.Despite the high prevalence, little is known about the factors hindering recovery following minor traffic-related injuries. The aim of this paper is to present a protocol for the systematic review aiming to understand biopsychosocial factors related to non-recovery and identify current gaps in the literature.

METHODS AND ANALYSIS

The review will be conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol guidelines. A search of the electronic databases, MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, will be undertaken, in addition to Google Scholar and grey literature to identify studies in period from 2006 to 2016. Quantitative and qualitative research articles describing and identifying biopsychosocial factors associated with non-recovery and health outcomes such as pain, disability, functional recovery, health-related quality of life, post-traumatic stress disorder, depression, anxiety and return to work will be included. A conceptual framework developed to identify biopsychosocial factors will be applied to assure defined criterion.At present, there is little anticipation for meta-analyses due to the heterogeneity of factors and outcomes assessed. Therefore, a narrative synthesis based on study findings will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required as primary data will not be collected. Review results will be published as a part of thesis, peer-reviewed journal and conferences.

TRIALREGISTRATION NUMBER

PROSPEROregistration number: CRD42016052276.

Traumatic injury and perceived injustice: Fault attributions matter in a "no-fault" compensation state

Background

Traumatic injury can lead to loss, suffering and feelings of injustice. Previous research has shown that perceived injustice is associated with poorer physical and mental wellbeing in persons with chronic pain. This study aimed to identify the relative association between injury, compensation and pain-related characteristics and perceived injustice 12-months after traumatic injury.

Methods

433 participants were recruited from the Victorian Orthopedic Trauma Outcomes Registry and Victorian State Trauma Registry, and completed questionnaires at 12–14 months after injury as part of an observational cohort study. Using hierarchical linear regression we examined the relationships between baseline demographics (sex, age, education, comorbidities), injury (injury severity, hospital length of stay), compensation (compensation status, fault, lawyer involvement), and health outcomes (SF-12) and perceived injustice. We then examined how much additional variance in perceived injustice was related to worse pain severity, interference, self-efficacy, catastrophizing, kinesiophobia or disability.

Results

Only a small portion of variance in perceived injustice was related to baseline demographics (especially education level), and injury severity. Attribution of fault to another, consulting a lawyer, health-related quality of life, disability and the severity of pain-related cognitions explained the majority of variance in perceived injustice. While univariate analyses showed that compensable injury led to higher perceptions of injustice, this did not remain significant when adjusting for all other factors, including fault attribution and consulting a lawyer.

Conclusions

In addition to the “justice” aspects of traumatic injury, the health impacts of injury, emotional distress related to pain (catastrophizing), and the perceived impact of pain on activity (pain self-efficacy), had stronger associations with perceptions of injustice than either injury or pain severity. To attenuate the likelihood of poor recovery from injury, clinical interventions that support restoration of health-related quality of life, and adjustment to the impacts of trauma are needed.

Return to Work After Traumatic Injury: Increased Work-Related Disability in Injured Persons Receiving Financial Compensation is Mediated by Perceived Injustice

Purpose Traumatic injury is a leading cause of work disability. Receiving compensation post-injury has been consistently found to be associated with poorer return to work. This study investigated whether the relationship between receiving compensation and return to work was associated with elevated symptoms of psychological distress (i.e., anxiety, depression, and posttraumatic stress disorder) and perceived injustice. Methods Injured persons, who were employed at the time of injury (n = 364), were recruited from the Victorian State Trauma Registry, and Victorian Orthopaedic Trauma Outcomes Registry. Participants completed the Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist, Injustice Experience Questionnaire, and appraisals of pain and work status 12-months following traumatic injury. Results Greater financial worry and indicators of actual/perceived injustice (e.g., consulting a lawyer, attributing fault to another, perceived injustice, sustaining compensable injury), trauma severity (e.g., days in hospital and intensive care, discharge to rehabilitation), and distress symptoms (i.e., anxiety, depression, PTSD) led to a twofold to sevenfold increase in the risk of failing to return to work. Anxiety, post-traumatic stress and perceived injustice were elevated following compensable injury compared with non-compensable injury. Perceived injustice uniquely mediated the association between compensation and return to work after adjusting for age at injury, trauma severity (length of hospital, admission to intensive, and discharge location) and pain severity. Conclusions Given  that perceived injustice is associated with poor return to work after compensable injury, we recommend greater attention be given to appropriately addressing psychological distress and perceived injustice in injured workers to facilitate a smoother transition of return to work.