On May 2, 2018, the South Central Regional SWAT team in Connecticut responded to a situation involving a barricaded subject. As the officers approached the home, the suspect set off an explosion in the garage that sent several team members hurtling 30 to 40 feet in the air. Nine officers sustained injuries, including concussions, leg and knee injuries, broken bones, and burns. To date, several of the officers remain out of work, months after the incident, secondary to their orthopaedic injuries.
The immediate response to traumatic-related injuries, such as those described here, is to send patients to a hospital. There, the focus is on stabilization of life-threatening injuries, treatment of open wounds, and fixation of fractures. After a treatment plan is established and enacted (e.g., surgery), the recovery process begins. The psychological factors that can dramatically affect the acute and long-term recovery from a traumatic physical injury often take a back seat to the acute issues of life and limb. Fortunately, the SWAT officers received psychological services immediately following the event and have continued to receive psychological intervention throughout their recovery process. The officers received immediate defusing and debriefing in the hospital, followed by a group debriefing one week after the event. They also had individualized follow-up by their employee assistance program, referral for ongoing treatment, and intervention for their families. This level of intervention, however, is the exception rather than the rule for most traumatic injuries.
Orthopaedic injuries can be life-changing events and classified as traumatic injuries no matter how they occur. Individuals who sustain such injuries experience not only physical limitations but also an attack on their emotional sense of well-being. Even athletes with sports-related injuries, particularly those with potentially long-term careers, are at risk. The hopes of a college scholarship may be put into question. Interactions among an injured athlete, the team, the coaches, and the hopeful parents can increase the emotional impact on the patient. Moreover, psychological factors secondary to traumatic physical injury can impact the recovery process in two ways: (1) the impact of stress on the body’s healing process and (2) the development of longer-term psychological conditions, which negatively impact the recovery process.
The effects of stress on healing
The impact of psychological stress on healing is well-established. Cortisol, also known as the stress hormone, is a major factor in this process. Elevations in cortisol interfere with the production of proinflammatory cytokines at the wound site, which are important early in the healing process. Studies have shown that psychological stress can extend healing time of wounds by 25 percent or more. Anxiety and depression can make pain worse, creating an additional stressor that can slow the healing process. Chronic stress causes the muscles in the body to be in a constant state of tension/guardedness, and that can interfere with post-operative therapy. When the state of tension is prolonged, it can cause pain perceptions to be exaggerated and, as a result, lead to chronic pain syndrome.
Little has been written about coping with or treating the psychological impact of traumatic injury and the subsequent recovery in the acute period. These sequelae are common and require many weeks to months to resolve. The trauma reactions can include:
- mental fatigue
- substance abuse
Patients can be faced with a shattered sense of physical security; the experience of living with the effects of severe pain; and the loss of income, a job, or sports-related opportunity. Patients require far more support to rebuild a healthy outlook on life than merely recovering from the physical injury/disability. The more deeply an individual’s sense of identity is connected to his or her physical form, ability, and performance, the greater the emotional reaction to a traumatic physical injury.
Orthopaedic injuries and PTSD
Depending on how an injury occurred, studies have shown that 20 percent to 50 percent of orthopaedic injuries can lead to post-traumatic stress disorder (PTSD), which can have a significant effect on an individual’s ability to function in everyday life, slow the rehabilitation process, and increase the risk for the development of chronic pain syndrome. Studies have shown that more than 50 percent of those suffering an orthopaedic injury will demonstrate psychological distress that can last for years after the physical injury has been treated.
Early identification of patients with psychological distress can help doctors provide the resources and support to offset it and minimize the negative impact on the recovery process. Many people have trouble thinking or talking about their feelings and emotions. Because there is a strong correlation between trauma and chronic pain, a combination of psychotherapy and physical therapy is the most effective treatment plan. The most effective psychotherapy utilizes cognitive-behavioral strategies, imagery, and training in relaxation techniques. Helping patients develop effective coping skills while avoiding catastrophic thinking is paramount to aiding the transition back to a premorbid state of functioning.
Orthopaedic surgeons who routinely question patients about emotional problems after injury have the best chance of identifying those at risk for PTSD. Recognizing the symptoms of PTSD early offers the best chance of effective prevention. Delaying treatment for trauma-related psychological conditions only allows the problems to grow worse and more intractable. Orthopaedic surgeons can improve patient outcomes by understanding signs and symptoms of PTSD and initiating referral and prevention strategies early in the treatment process.
Orthopaedic surgeons who treat patients with traumatic injuries should understand the following:
- An initial negative emotional reaction to an injury is normal. Physicians need to be aware of these “normal” reactions and provide education to their patients about this early in the treatment process.
- Referral to a clinical psychologist or other qualified mental health professional should be a routine part of the treatment plan for patients who have sustained a traumatic injury. It is important to destigmatize mental health issues and allow patients to understand the symptoms of emotional distress. Psychological counseling can assess and treat any psychological/emotional issues that can negatively impact the recovery process.
- Referral for psychological evaluation should occur even when an individual denies any emotional burden. Many individuals deny emotional problems, preferring to focus strictly on their physical injuries. It is important to remember that patients in need frequently are reticent to seek treatment because they view psychotherapy as a sign of weakness or failure.
- Early intervention is key. Appropriate and timely intervention can help prevent a longer recovery process, the development of chronic pain, PTSD, and other negative psychological conditions.
Mark J. Kirschner, PhD, ABPP, is a clinical psychologist and board-certified specialist in police and public safety psychology with Behavioral Health Consultants, LLC, in Hamden, Conn. He can be reached at firstname.lastname@example.org.