Predictors of non-return to work 2 years post-injury in road traffic crash survivors: results from the UQ SuPPORT study

Individuals who have sustained an injury from a road traffic crash (RTC) are at increased risk for long lasting health problems and non-return to work (NRTW). Determining the predictors of NRTW is necessary to develop screening tools to identify at-risk individuals and to provide early targeted intervention for successful return to work (RTW). The aim of this study was to identify factors that can predict which individuals will not RTW following minor or moderate injuries sustained from a RTC.Participants were 194 claimants (63.4% female) within a common-law "fault-based" system from the UQ SuPPORT cohort who were working prior to their RTC. Participants were assessed at 6 months on a variety of physical and mental health measures and RTW status was determined at 2 years post-RTC. RTW rate was 78.4%.Univariate predictors of NRTW included being the driver or passenger, having a prior psychiatric diagnosis, high disability level, low mental or physical quality of life, predicted non-recovery, high pain, low function, high expectations of pain persistency, low expectations about RTW, having a psychiatric diagnosis, elevated depression or anxiety. The final multivariable logistic regression model included only two variables: disability level and expectations about RTW. Seventy-five percent of individuals who will not RTW by 2 years can be identified accurately at an early stage, using only these two predictors.The results are promising, because they suggest that having information about two factors, which are easily obtainable, can predict with accuracy those who will require additional support to facilitate RTW

Recovery trajectories for long-term health-related quality of life following a road traffic crash injury: results from the UQ SuPPORT study

Background Diminished physical and mental health-related quality of life (HRQoL) is a common consequence of road traffic crash (RTC) injury. This study aimed to (a) determine the probable recovery trajectories in physical and mental HRQoL; (b) examine the impact of posttraumatic stress disorder (PTSD) on HRQoL scores within these trajectory groups; and (c) examine the influence of predictor covariates on trajectory group membership. Methods 336 (63% female, M =44.72; SD =14.77) injured RTC survivors completed the SF-36v2 at approximately 6, 12, and 24 months after sustaining a RTC injury. Participants also completed telephone interviews to assess prior history of psychological disorder and current PTSD at each wave. Results Three trajectories were identified for SF-36v2 Physical Component Score (PCS): ”gradual recovery” (27.3%);”low but improving” (54.7%); and”severe and chronic” (17.9%). Four trajectories were defined for SF36v2 Mental Component Score (MCS): “unaffected” (19.1%);”severe but improving” (24.1%);”severe and declining” (17.3%); and”low but improving” (39.5%). A PTSD diagnosis significantly reduced SF36v2 component scores only in trajectories associated with poorer outcome. Age was predictive of trajectory group membership for PCS, whereas injury severity was predictive of trajectory group membership for MCS. Limitations Use of a compensation seeking sample affects generalizability to the general RTC population. Conclusions This study identified a concerning subgroup of individuals who have chronic and/or declining physical and mental HRQoL that can be impacted by a diagnosis of PTSD. The development of interventions with a special focus on associated psychological injury is needed to improve the HRQoL of at-risk individuals following RTC injury

Changing patterns in the prevalence of posttraumatic stress disorder, major depressive episode and generalized anxiety disorder over 24 months following a road traffic crash: results from the UQ SuPPORT study

Objective: To examine the prevalence and changing patterns of PTSD, major depressive episode (MDE), and generalized anxiety disorder (GAD) in adult claimants who sustained a non-catastrophic injury in a road traffic crash (RTC) in Queensland, Australia. Method: Participants (N = 284) were assessed at approximately 6, 12, and 24 months post-RTC using the composite international diagnostic interview (CIDI) modules for PTSD, and CIDI-short form for MDE, and GAD. Results: The prevalence of at least one of these disorders was 48.2%, 52.5%, and 49.3%, at 6, 12, and 24 months, respectively. Comorbidity was common (20.8% at 6 months, 27.1% at 12 months, and 21.1% at 24 months) and only 33.1% of participants never met PTSD, GAD, or MDE criteria. A substantial proportion of participants (42.3%) had an unstable diagnostic pattern over time. Participants with multiple diagnoses at 6 months were more likely to continue to meet diagnostic criteria for any disorder at 12 and 24 months than participants with a single diagnosis. Participants with PTSD (with or without MDE/GAD) were more likely to meet criteria for any disorder at 24 months than participants with another diagnosis. Preinjury psychiatric history increased the likelihood of any disorder at 24 months post-injury, but did not significantly increase the likelihood of PTSD. Conclusions: People injured in a RTC are at risk of having complex psychological presentations over time. Interventions to prevent mental disorders, especially PTSD, in the early post-injury period are needed to prevent chronic psychological injury, including consideration of comorbidity and dynamic course

Rib fractures in blunt chest trauma: factors that influence daily patient controlled opiate use during acute care

Background: Opiates are frequently used in the inpatient management of chest wall injury following blunt trauma. However, the daily sum of opiates used during acute care, and the impact that additional injuries or rib fracture displacement may have on daily opiate requirement is unknown. Methods: A retrospective sample of 85 adult patients admitted to a tertiary trauma centre between April 2018 and October 2019 after a major chest wall injury (Abbreviated Injury Scale >2) and referral to Acute Pain Management Service was used in this study. Daily opiate usage was calculated each day for the first seven days following initial admission and converted to morphine milliequivalents (MME). Additional adjunct analgesia therapy was also recorded each day. The presence of rib fracture displacement and concurrent clavicle/scapular fractures was also noted. A comparison of the average daily MME for the various subgroups of interest was performed. Results: The maximum average MME in patients with rib fractures typically occurs at day 2 post injury and admission, with the highest day 2 average MME being in the Patient Controlled Analgesia (PCA) and ketamine subgroup. Presence of rib displacement delayed the onset of maximal MME to day 3 and resulted in higher average MME over the total seven days. Patients with concurrent clavicle or scapular fractures also had higher average MME each day, regardless of the addition of a regional block. Conclusions: This study has demonstrated the daily opioid requirement is maximal on day 2 post-admission following isolated major chest wall injury. The addition of a regional block resulted in a reduction of the average MME used each day over the first seven days post-admission, compared to ketamine when added to PCA. The presence of displaced rib fractures or clavicle/scapular fractures increased the MME used each day, changed the day of peak consumption and increased the average daily opioid requirement during acute hospitalisation.</p

The effect of mental health on long-term health-related quality of life following a road traffic crash: Results from the UQ SuPPORT study

Background Most research on the consequences of road traffic crashes (RTCs) has focused on serious injury cohorts, yet RTC survivors with minor injury are also affected. This study investigates the relationship between mental health and health-related quality of life (QoL) following an RTC for those with predominately minor injuries. Methods A longitudinal cohort design with an opt-in consenting procedure was used. A letter of invitation was sent to 3146 claimants within the Compulsory Third Party (CTP) motor vehicle insurance scheme in Queensland, Australia, with a total of 382 (12%) responding to the invitation and consenting to participate in the study. Retention was high (65%) at 24 months. Survey and telephone interview data were collected at approximately 6, 12 and 24 months post-RTC. Health-related QoL (SF-36 v2) data from at least one wave was known for 343 participants. The sample was predominantly female (62%), with an average age of 48.6 years. Results Participants consistently reported physical and mental health-related QoL below Australian norms. A multilevel regression analysis found overall physical health-related QoL improved with higher expectations of returning to work, but was lower with age, increasing pain, expectations of persistent pain, heightened perceived threat to life, and the presence of Posttraumatic Stress Disorder (PTSD) or Major Depressive Episode (MDE). Overall, mental health-related QoL did not improve with time, was higher with increased social support and expectations of returning to work, but was lower with increasing pain and the presence of PTSD, MDE or Generalised Anxiety Disorder (GAD). Contrary to expectations, lower injury severity was related to poorer mental health-related QoL. Conclusions Individuals with predominately minor RTC-related injuries have poor physical and mental health-related QoL, particularly when pain levels are high and comorbid psychiatric disorders are present. Of particular concern is that the low levels of reported health-related QoL do not appear to improve by 2 years post-RTC. The potential risk factors found in this study may be useful indicators for early identification and enhanced rehabilitation of those at risk of poor recovery

Exercise induced hypoalgesia is impaired in chronic whiplash associated disorders (WAD) with both aerobic and isometric exercise

Objectives: Exercise induced hypoalgesia (EIH) can be impaired in patients with chronic pain and may be dependent on exercise type. Factors predictive of EIH are not known. This study aimed to: (1) compare EIH in participants with chronic WAD to asymptomatic controls, (2) determine if EIH differs between aerobic and isometric exercise, (3) determine predictors of EIH. Methods: A pre-post study investigated the effect of single sessions of submaximal aerobic treadmill walking and isometric knee extension on EIH in 40 participants with chronic whiplash associated disorders (WAD) and 30 controls. Pressure pain thresholds were measured at the hand, cervical spine and tibialis anterior. Pain intensity, reported previous week physical activity, temporal summation and conditioned pain modulation (CPM) were measured at baseline. Results: Participants with WAD demonstrated impaired EIH. Whilst, the WAD participants demonstrated a partial EIH response (EIH induced at the hand during exercise), no EIH response was found immediately after exercise. There was no difference in EIH between exercise types. In the WAD group, moderate physical activity levels predicted EIH at the hand and high physical activity levels predicted impaired EIH at the neck. More efficient CPM predicted EIH at the hand and less efficient CPM predicted impaired EIH at the neck. These associations were found for isometric exercise only. Discussion: Individuals with chronic WAD have impaired EIH with both aerobic and isometric exercise. Higher levels of physical activity and less efficient CPM may be associated with impaired EIH. This may have implications for exercise prescription in this patient group

Comparing the accuracy of ICD-based severity estimates to trauma registry-based injury severity estimates for predicting mortality outcomes

Introduction: Trauma registries have been used internationally for several decades to measure the quality of trauma care between hospitals. Given the significant costs involved in establishing and maintaining trauma registries, and increasing availability of routinely collected, linked health data describing a patient's journey (and inherent cost savings in data re-use), there is significant interest in development of integrated, comprehensive trauma data repositories. However, approaches to estimating injury severity using routinely collected data would need to be developed if routinely collected hospital data were to be used as an alternative/supplement to registries. Objectives: This study aimed to compare the accuracy of registry-based injury severity estimates with ICD-based injury severity estimates in predicting mortality outcomes in a cohort of minor and major trauma patients in Queensland, using retrospectively linked trauma registry and hospital admissions data. Methods: Queensland Trauma Registry (QTR) data with an admission date between 1 January 2005 and 31 December 2011 was linked with all acute care patients included in the Queensland Hospital Admitted Patient Data Collection (QHAPDC) with a Principal Diagnosis coded with an ICD-10-AM code within Chapter 19 (S00–T98). Abbreviated Injury Scale coding was undertaken manually by QTR trauma data nurses for the registry data. ICD-based injury severity scores (ICISS) were calculated automatically using all injury-related diagnoses captured in the QHAPDC data using the ICISS multiplicative and worst injury method. Results: There were 92,140 QTR patients admitted between January 2005 and December 2011 with a valid ISS with a matching QHAPDC record (98.4% survived, 1.6% died). ICISS (multiplicative and worst injury approach) showed marginally better predictive accuracy than ISS when predicting mortality across minor and major injury and ICISS showed marginally better predictive accuracy to ISS when restricted to major trauma/high threat to life cases. Both ICISS and ISS restricted to major trauma/high threat to life showed poorer accuracy compared to the predictive performance when both minor and major cases were included. Conclusion: ICD-based predictions were as accurate as ISS-based predictions for this cohort and this study provides evidence to support the potential for using routinely coded hospital data for risk adjustment within State-based trauma data repositories.</p

Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): A randomised controlled trial of a combined psychological/physical intervention

There are few effective treatments for acute whiplash-associated disorders (WAD). Early symptoms of postinjury stress predict poor recovery. This randomised controlled trial (StressModex) investigated whether physiotherapist-led stress inoculation training integrated with exercise is more effective than exercise alone for people with acute WAD.108 participants

Effect of mental health on long-term disability after a road traffic crash: Results from the UQ SuPPORT study

Objective To investigate the relation between mental health and disability after a road traffic crash (RTC) up to 24 months for claimants with predominantly minor injuries in an Australian sample. Design Longitudinal cohort study with survey and telephone interview data collected at approximately 6, 12, and 24 months post-RTC. Setting Not applicable. Participants Claimants (N=382) within a common-law, fault-based compulsory third-party motor accident insurance scheme in Queensland, Australia, consented to participate when invited and were approached at each wave. Retention was high (65%) at 2-year follow-up. Disability scores from at least 1 wave were known for 363 participants, with the mean age of participants being 48.4 years and 62% being women. Interventions Not applicable. Main Outcome Measure Self-reported disability (via the World Health Organization Disability Assessment Schedule 2). Results Participants reported higher disability (mean, 10.9±9.3) compared with the Australian norms (mean, 3.1±5.3). A multilevel regression analysis found that predictors of disability included present diagnosis of posttraumatic stress disorder (PTSD), anxiety, or depression, mental health history, perceived threat to life, and pain. PTSD moderated the relation between age and disability such that older age predicted higher disability in the PTSD group only, whereas anxiety moderated the relation between expectation to return to work and disability such that those with low expectations and anxiety reported significantly higher disability. Conclusions Claimants with predominantly minor physical injuries report high disability, particularly when comorbid psychiatric disorders are present, pain is high, and expectations regarding return to work are low. Developing tools for detecting those at risk of poor recovery after an RTC is necessary for informing policy and practice in injury management and postinjury rehabilitation

Identifying risk of poor physical and mental health recovery following a road traffic crash: an industry-specific screening tool

This study aimed to develop an industry-specific tool to identify risk of poor physical and mental recovery following minor to moderate injuries sustained in a road traffic crash (RTC). Existing tools are often designed for implementation by health professionals rather than insurer case managers who may not have a background in health. This study is a secondary analysis of a longitudinal cohort study using data collected at 2–6 months and 24 months post-RTC. Participants were claimants (n = 254; Mean age = 50 years; 65% female) with mild-moderate injuries recruited through the common-law ‘fault-based’ compulsory third party scheme in Queensland, Australia. Sociodemographic, functional and psychological health factors were collected at baseline (2–6 months post RTC) and used as potential predictors for physical and mental health-related quality of life (Short Form 36 v2) at the 2-year follow-up. The LASSO (Least Absolute Shrinkage and Selection Operator) analysis identified six disability items (from the World Health Organization Disability Assessment Schedule 2) to predict poor physical and one item to predict poor mental health-related quality of life. Logistic regressions of these items in addition to age and gender were used to develop a screening tool. Using the tool, 90% of those at risk of poor physical and 80% of those at risk of poor mental health-related quality of life were identified correctly. To conclude, this study presents an 8-item, context-specific tool to help injury managers identify individuals at risk of poor physical and mental health recovery following mild-moderate RTC-related injuries. The tool requires validation in a new cohort and confirmation of acceptability by end-users