PTSD occurs with significant frequency in civilian patients after traumatic event involving physical injury

Recognizing early signs is critical to effective treatment

Although most commonly associated with military combat, post-traumatic stress disorder (PTSD) can occur in civilians, too - and with consequences that are just as serious, according to a new review article in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). PTSD is a type of anxiety disorder that occurs after a person experiences a traumatic event involving physical injury, and occurs in 20 to 51 percent of patients with an orthopaedic injury.

"PTSD occurs with a significant frequency in civilian patients who have sustained an orthopaedic trauma, and it can hinder their emotional, physical and functional recovery following orthopaedic treatment," said Daniel Aaron, MD, a clinical instructor in the department of orthopaedics at Brown University in Providence, R.I.

Many types of accidents can cause PTSD, including car or motorcycle accidents, gunshot wounds, vehicle-pedestrian accidents and falls from height, among many others.

"Generally, higher-energy mechanisms are most commonly associated with PTSD, but no specific type of fracture or injury has been identified," Dr. Aaron said. "Basically, any type of muscuolskeletal injury that results from significant trauma may be associated with PTSD."

PTSD can have a significant impact on a patient's ability to perform simple, daily chores, and can slow the rehabilitation process, even affecting how the patient experiences pain and perceives his or her recovery.

"The development of PTSD adversely affects the ability of the patient to recover and may specifically compromise physical rehabilitation and patient satisfaction following orthopaedic treatment," Dr. Aaron said. "Without effective treatment, PTSD can hinder activities of daily living, such as bathing, eating, paying bills, shopping, laundry and other household chores. Patients with PTSD also may be delayed in returning to work."

A diagnosis of PTSD relies on the presence of specific behaviors or symptoms, including:

• re-experiencing the traumatic event, including nightmares, flashbacks and intrusive memories;
• avoiding situations reminiscent of the original trauma, reluctance to talk or think about the original trauma, or feeling emotionally "numb" about the event; and,
• anger, irritability, difficulty concentrating, insomnia and/or an increased startle response.

In addition, the symptoms must have occurred for at least one month and they must be severe enough to cause a noticeable change in normal behavior.

PTSD can occur in any person at any age, but Dr. Aaron said several risk factors make PTSD more likely to occur, including:

• use of drugs or alcohol;
• less education;
• lower socioeconomic status;
• young age; or
• female gender.

One study also suggests people of Hispanic origin may be at greater risk for PTSD, he added.

"Although no single prevention protocol has been described, therapy with a psychiatrist or psychologist may help, as well as the use of certain medications, including anti-depressants and anti-anxiety medications," Dr. Aaron said.

Recognizing the symptoms of PTSD early offers the best chance of effective prevention. Orthopaedic surgeons can improve patient outcomes by knowing which patients are at risk of developing PTSD and initiating prevention strategies, noted Dr. Aaron. Some studies indicate that when PTSD is identified early, progression of the condition may be prevented through use of medications, he added.

"Identifying at-risk patients is an important first step in preventing the ill effects of PTSD," he said. Many orthopaedic surgeons may not recognize the signs and symptoms of PTSD, and remain unaware of prevention and treatment strategies. As a result, recovery can be delayed.

In addition to understanding and evaluating for the risk factors of PTSD, asking patients questions about the emotional and physical problems they are experiencing as a result of their injury can also help physicians determine if a patient is at risk for developing the condition.

Treatment of PTSD begins with referral to a psychiatric professional, who may prescribe medication and implement a behavioral therapy program to help deal with the traumatic event and its effects.

Although PTSD clearly impacts recovery in patients with orthopaedic injury, currently there are no studies that directly link treatment or resolution of PTSD with orthopaedic improvement, and many of the options for treatment of PTSD are in the experimental stage, Dr. Aaron noted.

"In addition to continuing to look at treatment options and their effects, we need to study the effectiveness of prevention strategies," he said. "And we also need to look at whether physical and functional outcomes do indeed improve as the emotional symptoms of PTSD are treated."