Identification of clinically-useful cut scores of the Traumatic Injuries Distress Scale (TIDS) for predicting rate of recovery following musculoskeletal trauma

Cortisol as a Marker of Pain and Distress After Acute Musculoskeletal Trauma

OBJECTIVES

The best available predictors of chronic pain development broadly encompass baseline metrics of cognition (ie, beliefs/expectations) about the trauma and resulting symptoms. In the context of musculoskeletal trauma, we have previously shown the Traumatic Injuries Distress Scale (TIDS) capable of risk-stratifying cohorts for chronic pain development. Here, we explore whether the physiological marker cortisol shows meaningful associations with cognitions predictive of pain outcomes.

METHODS

Data for these cross-sectional analyses were drawn from an observational study that recruited 130 participants presenting to the hospital with pain related to a recent noncatastrophic Musculoskeletal trauma. Cortisol was measured from the participant's hair, saliva, and blood. In addition to pain and distress questionnaires, metadata such as age, sex, body mass index (BMI), adverse childhood events, pretrauma stress levels, and pre-existing physical/psychological comorbidities were collected.

RESULTS

We found no significant associations between cortisol levels and pain or distress in isolation. When stratified by person-level variables, associations were revealed with distress (TIDS) in young age and low pretrauma stress subgroups (hair cortisol) and low BMI (blood cortisol). Through hierarchical regression analysis, we found the "cortisol X age" or "cortisol X stress" interaction terms significantly improved TIDS prediction beyond either variable in isolation (Age: ∆ R2 =15.1%; pretrauma stress: ∆ R2 =9.1%).

DISCUSSION

Our findings suggest that while linear correlations between pain-related distress and cortisol may be overly simplistic, certain person-level variables such as age, pretrauma stress, and BMI are worthy of consideration for experimental design or confounder characterization in future studies of pain and distress following musculoskeletal injuries especially when "trait" (hair) cortisol is the predictor variable.

Biopsychosocial sequelae and recovery trajectories from whiplash injury following a motor vehicle collision

BACKGROUND CONTEXT

Five out of 10 injured in a motor vehicle collision (MVC) will develop persistent pain and disability. It is unclear if prolonged symptoms are related to peritraumatic pain/disability, psychological distress, muscle fat, lower extremity weakness.

PURPOSE

To test if widespread muscle fat infiltration (MFI) was (1) unique to those with poor recovery, (2) present in the peritraumatic stage, (3) related to known risk factors.

STUDY DESIGN/SETTING

A cohort study, single-center academic hospital.

PATIENT SAMPLES

A total of 97 men and women (age 18-65) presenting to an urban academic emergency medicine department following MVC, but not requiring inpatient hospitalization.

PRIMARY OUTCOME MEASURE

Neck disability at 12-months.

METHODS

Participants underwent magnetic resonance imaging (MRI) to quantify neck and lower extremity MFI, completed questionnaires on pain/disability and psychological distress (< 1-week, 2-weeks, 3-, and 12-months) and underwent maximum volitional torque testing of their lower extremities (2-weeks, 3-, and 12-months). Percentage score on the Neck Disability Index at 12-months was used for a model of (1) Recovered (0%-8%), (2) Mild (10%-28%), and (3) Moderate/Severe (≥ 30%). This model was adjusted for BMI and age.

RESULTS

Significant differences for neck MFI were revealed, with the Recovered group having significantly lower neck MFI than the Mild and Moderate/Severe groups at all time points. The Mild group had significantly more leg MFI at 12-months (p=.02) than the Recovered group. There were no other significant differences at any other time point. Lower extremity torques revealed no group differences. The Traumatic Injury Distress Scale (TIDS) and MFI of the neck at 1-week postinjury significantly predicted NDI score at 12-months.

CONCLUSIONS

Higher neck MFI and distress may represent a risk factor though it is unclear whether this is a pre-existing phenotype or result of the trauma.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02157038.

Cross-cultural translation and validation of the traumatic injuries distress scale - Spanish version

PURPOSE

The Traumatic Injuries Distress Scale is a patient-reported measure capturing experiences of distress following non-catastrophic musculoskeletal injuries. The original English version has shown adequate accuracy for predicting recovery trajectories up to 12 months later. Herein we describe the translation of the English TIDS into the TIDS-Spanish.

MATERIALS AND METHODS

The prototype version was developed through a two-step forwards-back translation involving four independent bilingual speakers. 73 participants (51% female, mean age 47 years, 32% acute) with musculoskeletal pain responded to the prototype through an online platform or in paper format through a single administration. A series of hypotheses including correlation with an external standard and factor structure were tested for both concurrent and factorial validity compared to those of the English version.

RESULTS

Despite an overall higher mean TIDS score in the Spanish-speaking participants compared to the original English development cohort, all hypotheses for concurrent associations with external pain criteria were satisfied and the three-factor structure of the original was replicated in the new TIDS-Spanish (CFI = 0.97, TLI = 0.96, RMSEA = 0.05).

CONCLUSION

While prospective data collection is needed to explore the equivalence in prognostic validity, all other analyses indicated psychometric equivalence of the new TIDS-Spanish with the original English version. Implications for RehabilitationThe Traumatic Injuries Distress Scale has previously shown prognostic validity for stratifying people with acute musculoskeletal injury into risk-recovery trajectories.A Spanish-translated version of the TIDS was developed and evaluated for psychometric equivalence with the original English version.Results indicate that we were successful in creating a conceptually and empirically equivalent version of the TIDS for use in Spanish-speaking populations.

How Is the Probability of Reporting Various Levels of Pain 12 Months After Noncatastrophic Injuries Associated with the Level of Peritraumatic Distress?

BACKGROUND

Psychological factors have been shown to be consistent predictors of chronic pain in people with musculoskeletal injuries. However, few prognostic studies have considered multiple risk factors including peritraumatic distress. In addition, previous research has not considered that the associations between peritraumatic distress and pain levels can vary across pain outcomes.

QUESTION/PURPOSE

To determine whether an easily measurable level of baseline distress is associated with pain levels 1 year after noncatastrophic traumatic injuries when the outcome to be assessed is not normally distributed.

METHODS

This was a prospective cohort study. The data were captured from two cohorts in London, Ontario, Canada, and Chicago, IL, USA. Participants were adults with acute noncatastrophic (that is, not treated with surgery or hospitalization) musculoskeletal injuries of any etiology with various injury locations (60% [145 of 241] spinal and 40% [96 of 241] peripheral) that presented to local urgent care centers. Other inclusion criteria included English/French speakers and having no other disorder that would affect their pain levels. In total, between the years 2015 and 2018, 241 participants were recruited based on the inclusion criteria. Ninety-three percent (225 of 241) of participants provided baseline data, and of these, 48% (109 of 225) were lost to follow-up in 1 year. Based on a complete case approach, this study included 116 participants who ranged in age from 18 to 66 years and 69% (80) of whom were women. The Traumatic Injuries Distress Scale (TIDS) was used to evaluate distress at baseline (within 4 weeks of injury). The TIDS is a validated, reliable 12-item risk prognosis screening tool that takes less than 3 minutes to complete with questions regarding uncontrolled pain, negative affect, and intrusion/hyperarousal. The minimum and maximum possible scores are 0 and 24, with higher scores indicating higher levels of distress. The Numeric Pain Rating Scale (NPRS) was used to assess the pain level at baseline and again 12 months postinjury. To complete the NPRS, participants rate the severity of their pain on a scale of 0 to 10, with 0 indicating no pain and 10 indicating the worst pain imaginable. NPRS scores of 1 to 3 indicate mild pain, 4 to 6 indicate moderate pain and 7 or higher indicate severe pain. As a preliminary analysis, to assess whether the participants as a group experienced recovery, a paired samples t-test was used to compare NPRS scores at baseline and 12 months. In all, 52% (60 of 116) of participants reported no pain (NPRS = 0), and mean pain intensity scores improved from 4.8 ± 2.1 at baseline to 1.6 ± 1.6 at 12-month follow-up (p < 0.001). Quantile regression was used to describe the association between baseline distress and pain levels 1 year after the injury. This technique was used because it reveals the relationships at different quantiles of the pain outcome distribution.

RESULTS

The results indicate some people (52% [60 of 116]) recovered regardless of their baseline level of distress (30th quantile of the NPRS: β = 0). However, in those with persisting pain, higher levels of baseline distress are associated with greater levels of pain 12 months after the injury (50th quantile of the NPRS: β = 0.11; p = 0.01; 70th quantile of the NPRS: β = 0.27; p < 0.001; 90th quantile of the NPRS: β = 0.31; p = 0.01). According to this model, with a baseline TIDS score of 5, there is 10% probability that patients will report moderate or greater levels of pain (4 or higher of 10) 12 months later. This probability then increases as the TIDS score increases. For instance, at a score of 13 on the TIDS, the probability of a patient reporting moderate or higher levels of pain increases to 30%, and the probability of reporting severe pain (higher than 6 of 10) is 10%.

CONCLUSION

Clinicians and surgeons in orthopaedic settings can screen for the presence of peritraumatic distress using the TIDS, which is an easily administered tool that does not require extensive knowledge of psychology, and by using it they can identify those with higher levels of distress who are more likely to have persistent, long-term pain. A score of 4 or less indicates a low risk of persistent pain, a score between 5 and 12 (endpoints included) indicates moderate risk, and a score of 13 or higher indicates high risk. Future studies should investigate whether certain immediate interventions for peritraumatic distress in the aftermath of trauma can decrease the likelihood that a patient will develop chronic pain after injury. As an analysis technique, quantile regression is useful to assess complex associations in many orthopaedic settings in which a certain outcome is expected to occur in most patients leading to non-normally distributed data.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Effects of childhood trauma on pain-related distress in adults

BACKGROUND

Much of the work in post-musculoskeletal (MSK) trauma and distress has been conducted through frameworks that start from the injury and go forward to better understand the trajectories and predictors of recovery. However, stress-diatheses models suggest that reactions to trauma are shaped by pre-existing experiences of the person more than the parameters of the event itself. In this study, we explore the effects of adverse childhood experiences (ACEs) on traumatic threat appraisal, distress and pain-related functional interference in adulthood.

METHODS

Adult participants with acute, non-catastrophic musculoskeletal trauma completed a battery of questionnaires that included the Adverse Childhood Experiences Questionnaire (ACEQ), the Brief Illness Perceptions Questionnaire (BIPQ), the Traumatic Injuries Distress Scale (TIDS) and the Brief Pain Inventory (BPI). An a priori model was evaluated through path analysis to determine the variance in BPI Interference scores explained through direct or indirect pathways between these variables (ACEQ->BIPQ, BIPQ->TIDS, TIDS->BPI). The analysis was repeated for the sample when disaggregated by sex.

RESULTS

In n = 114, the base model was saturated. After removing non-significant pathways, the ACEQ->BIPQ->TIDS->BPI paths were significant and in the expected direction, explaining 57.1% of variance in acute BPI Interference score. When disaggregated by sex, the effect of ACEs on threat appraisal was only significant in men and not women, although this analysis was exploratory.

CONCLUSIONS

Acute pain-related interference could be predicted by post-traumatic distress and threat appraisal. Threat appraisal could be further predicted through ACEs, more childhood adversities were associated with more threatening appraisal of trauma in adulthood. The disaggregated finding that the effects of childhood adversities were only significant in males requires further exploration.

SIGNIFICANCE

This study explores the potential pathways of the stress-diathesis model while focusing on adverse childhood experiences as a novel contribution to the field of acute post-trauma pain. The findings may inform future research design and interpretation of acute-to-chronic pain risk stratification tools.