BRIEF REPORT
Physical and mental health 10 years after multiple trauma: A prospective cohort study Helene L. Soberg, PT, PhD, Erik Bautz-Holter, MD, PhD, Arnstein Finset, PhD, Olav Roise, MD, PhD, and Nada Andelic, MD, PhD, Oslo, Norway
BACKGROUND: People who have sustained severe multiple injuries have reduced health and functioning years after the injury. For people who have sustained severe injuries, an optimal degree of predictability in future functioning and health-related quality of life is important. The main aim was to study the impacts of demographic- and injury-related factors as well as functioning at 1 year and 2 years after injury on physical and mental health 10 years after injury. METHODS: Fifty-eight participants completed a 10-year follow-up (55.2% of all included patients). Demographic and injury severity characteristics were collected, and assessments at 1, 2, 5, and 10 years after injury were performed. Patient-reported outcome measures were the Short Form 36 (SF-36), the Brief Approach/Avoidance Coping Questionnaire, and the cognitive function scale (COG). The SF-36 Physical and Mental Component Summaries (PCS and MCS, respectively) were the main outcome variables. We performed hierarchical multiple regression analyses to assess functioning on the PCS and MCS. RESULTS: Mean (SD) age at injury was 37.8 (14.7) years, 74% were male. Mean (SD) New Injury Severity Score (NISS) was 33.7 (13.0). Mean (SD) PCS score was 41.8 (11.7). Mean (SD) MCS was 48.8 (10.7). Predictors of the PCS were change in coping from 2 years to 10 years (p = 0.032), physical functioning (p G 0.001) and cognitive functioning at 1 year (p = 0.011), as well as bodily pain at 2 years (p = 0.005). Adjusted R2 was 0.57. Predictors of the MCS were change in coping (p = 0.031), vitality (p = 0.008) at 1 year, as well as social functioning (p = 0.034) and mental health (p = 0.043) at 2 years. Adjusted R2 was 0.64. CONCLUSION: Physical health was reduced compared with the adjusted general population at 10 years after injury. The mental health did not differ from that of the general population. In addition to physical functioning, coping strategies, vitality, social functioning, and mental health should be considered in the long-term rehabilitation perspective. A more comprehensive approach should be used for rehabilitation after multiple injuries. (J Trauma Acute Care Surg. 2015;78: 628Y633. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) KEY WORDS: Follow-up studies; multiple trauma; outcomes assessment (health care); rehabilitation.
T
raumatic injuries are the most frequent cause of death and disability, particularly among the working age population.1,2 People who have sustained severe multiple injuries have reduced health and functioning years after the injury.3Y7 In addition to the reduced physical and mental health, coping strategies and other personal and injury characteristics affect the health-related quality of life (HRQL).8Y10 In a study assessing people 2 years to 7 years after injury, 80% reported a reduced quality of life, and 50% reported problems in more than one dimension on EuroQol-5D.4 In addition, anxiety and Submitted: April 18, 2014, Revised: October 30, 2014, Accepted: November 4, 2014. From the Division of Surgery and Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, (H.L.S., E.B.-H.,N.A.), and Orthopedic Department (O.R.), Oslo University Hospital, Oslo; and Faculty of Medicine, Department of Behavioural Science, Institute of Basic Medical Sciences (A.F.), and Institute of Clinical Medicine, (O.R., E.B.-H.), and Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM) (N.A.), University of Oslo, Oslo, Norway. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com). Address for reprints: Helene L. Soberg, Oslo University Hospital, Division of Surgery and Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Postbox 4956 Nydalen, 0424 Oslo, Norway; email: [email protected], [email protected]. DOI: 10.1097/TA.0000000000000541
depression were reported 4 years after severe multiple injuries or spinal cord injury.10 Better coping abilities predicted the work status of workers with extremity injuries.11 Optimism and pain predicted functional health several years after injury.10 Injury severity can have differing impact on health and functioning over time.4,7 In some studies, having a traumatic brain injury (TBI) among the injuries resulted in more disability,2,12,13 worse psychological functioning, and more chronic pain.3 In our previous publications, a history of TBI was not predictive of self-reported health and functioning.5,14 For people who have sustained severe injuries, an optimal degree of predictability in future functioning and HRQL is important. There is a paucity of research related to long-term outcome, which here is defined as up to 10 years after injury. This concerns which injury- and rehabilitation-related factors as well as aspects of functioning are associated with long-term physical and mental health.3 In addition, few studies have examined factors that predict physical and mental health 10 years or more after multiple injuries or TBI.3,15 To our knowledge, there are no prospective studies that have studied changes in physical and mental health in the long-term perspective after severe multiple injuries and the association between functioning in the postacute rehabilitation phases and functioning at 10 years. The aim of this study was to examine the physical and mental health of a cohort who sustained severe multiple injuries J Trauma Acute Care Surg Volume 78, Number 3
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10 years previously. We wanted to study the changes in health and functioning from 5 years to 10 years after injury and differences in functioning at 10 years when compared with the general population. Finally, the aim was to study which demographic and injury-related factors and functioning at 1 and 2 years, that predict health at 10 years. We hypothesized that physical functioning and pain would predict physical health and that social functioning and mental health would predict mental health at 10 years. We also assumed that a more approach-oriented coping strategy would predict both physical and mental health.
PATIENTS AND METHODS Patients This study constitutes the 10-year follow-up of patients with severe multiple injuries; it is the continuation of a prospective cohort study with follow-ups conducted upon return home and at 1, 2, and 5 years after injury. It was performed at Oslo University Hospital (OUH), Norway, a regional trauma referral center with a population base of 2.5 million inhabitants in 2002. The study population consists of patients aged 18 years to 67 years at the time of injury who were admitted to the hospital within 24 hours after the injury from January 2002 through June 2003. Patients who participated in the 10-year follow-up are included in the current study. The inclusion procedure and criteria have been previously described.16 Briefly, patients with a New Injury Severity Score (NISS) of 16 or greater and at least two injuries classified according to the Abbreviated Injury Scale (AIS) scoring system were included.17,18 The exclusion criteria were a history of multiple injuries, burn injuries, substance addiction or severe psychological disease, and malignant or progressive diseases. Only people included in the 5-year follow-up were contacted for this 10-year follow-up. One-hundred five participants were originally enrolled in the study (Fig 1); the follow-up rates were 99% and 94% at 1 year and 2 years, respectively, and 80% at 5 years. Fifty-eight people (55.2%) participated in the 10-year follow-up. The participants gave written informed consent. The Regional Committee for Medical Research Ethics approved the study (#2012/81).
Measurements The patient outcomes were assessed by self-report questionnaires. The baseline data and functioning from assessments at 1, 2, 5, and 10 years after injury are presented. We recorded the following demographic data: age, sex, education, and profession. Education was dichotomized into elementary school/high school and college/university. Profession was categorized into (1) nonphysical work/being a student, (2) physical work, and (3) receiving a disability or retirement pension or unemployed. Coping, injury severity variables, and cognitive functioning were candidate predictor variables. Coping was assessed using the Brief Approach/Avoidance Coping Questionnaire (BACQ), which has 12 items.19 The BACQ is scored from 1 (disagree completely) to 5 (agree completely). A higher score indicates use of more approach-oriented coping strategies. The BACQ has satisfactory psychometric properties.19 We evaluated
Figure 1. Flow chart of patient inclusion.
the change in coping from 2 years to 10 years.20 Internal consistency measured with Cronbach’s > was 0.64 at 2 years in our sample of 58 participants.8 Injury severity data were extracted from the trauma registry at OUH. In the AIS, injuries are graded from 1 (minor injury) to 6 (maximum injury).18 The NISS is the sum of the squared AIS scores from each of the three most severe injuries.17,21 The Glasgow Coma Scale (GCS) score ranges from 3 to 15 (no response to normal consciousness).22 Length of stay in hospital/rehabilitation institution was registered. The COG is a scale for self-reported cognitive functioning used in trauma research.23 The COG evaluates how much of the time in the past 4 weeks the respondents experienced cognitive problems. The scale range is 0 to 100 (worst to best). The main outcome was assessed by the Short Form 36 (SF-36),24 which includes self-reported physical functioning, role-physical functioning, bodily pain, general health, vitality, social functioning, role-emotional functioning, and
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TABLE 1. Demographic and Injury Characteristics for the 58 Participants at the Time of Injury Demographic and Injury Characteristics Sex, men, n (%) Age at injury, mean (SD), y Education at time of injury, n (%) e12 y (high school) 912 y (university level) Profession at the time of injury, n (%) Blue collar White collar Retired No. injuries, mean (SD) NISS, mean (SD) Head AIS score (n = 34), mean (SD) GCS score, median (IQR) Weeks in hospital/rehabilitation institution, median (IQR)
43 (74.1) 37.8 (14.7) 37 (68.3) 21 (36.2) 34 (58.6) 22 (37.9) 2 (3.4) 7.6 (3.7) 33.7 (13.0) 2.9 (1.0) 15 (8Y15) 10.4 (3.0Y14.9)
IQR, interquartile range.
mental health.25 The scale range is 0 to 100 (worst to best). Norwegian general population data based on a sample of more than 2,300 people are available.26 The eight subscales can be aggregated into the Physical Component Summary (PCS) for physical health and the Mental Component Summary (MCS) for mental health.27 The oblique (correlated) PCS and MCS scores are applied as the main outcome variables.27 We computed the respective scores based on Norwegian reference data with an online calculator accessed at http://www.sf-36.org/ nbscalc/index.shtml. The PCS and MCS scores are norm based; the population means are 50 points, and 10 points refers to 1 SD. A 5-point difference is considered a minimally important change.28 PCS and MCS scores of less than 40 points (91 SD) indicate poor health.29
Data Analysis and Statistical Analysis Descriptive statistics, including cross-tabulations with W2 tests, were used. Correlations were analyzed with the Spearman’s Q or Pearson’s r. t tests and Mann-Whitney U-test were used to compare groups. Population norms adjusted for age and sex were compared with the study population with a two-sample t test. To explore the impact of functioning at 1 year and 2 years, hierarchical linear regression analyses were performed with the PCS and MCS at 10 years as outcome variables. We applied
statistical (p e 0.1 in the univariate regression, and intercorrelation coefficients G 0.8) and clinical criteria for selecting independent variables for the regression analyses. We tested postinjury functioning at 1 year and 2 years and the change in coping strategies from 2 years to 10 years in regression models with a manual backward procedure for each step separately first. We then used the significant variables from each step in a regression analysis. For the PCS, the variables were time in hospital/rehabilitation, physical function, bodily pain, vitality, and cognitive function at 1 year and 2 years and change in coping from 2 years to 10 years. For the MCS, the variables were vitality and cognitive function at 1 year, social function and mental health at 2 years, and change in coping from 2 years to 10 years. Age and sex were added in the final models for PCS and MCS to adjust for the population heterogeneity. The SF-36 scales were ln-transformed to improve the distribution. The multicollinearity, residuals, and influential data point checks showed that the assumptions of the regression models were not violated (Cook distance [D G 0.1]; Centered Leverage value [G0.2]). All variables in the analyses had 10% or fewer missing cases. The results of the final regression models are presented with R2, adjusted R2 and F, and standardized A values. p e 0.05 was considered statistically significant. We performed sensitivity analyses and imputed the 25% and 75% quartiles for missing PCS and MCS scores to test more realistic models (Appendix). IBM SPSS 21 was used for the analyses, and we used openepi.com (http://www.openepi.com/v37/Menu/ OE_Menu.htm) to test the differences between our study population’s functioning at 10 years and the population norm.
RESULTS The mean (SD) age of the 58 participants at 10 years after injury was 47.8 (14.7) years; 74% were men. The demographic and injury characteristics are shown in Tables 1 and 2. Thirty-five percent of the participants at 10 years received disability pension. There were some differences in baseline characteristics between the participants and nonparticipants at 10 years. Individuals lost to follow-up were younger (p = 0.039), were men (p = 0.008), had lower education (p = 0.014), and had more severe TBI (p = 0.038) than the participants did. The results of the sensitivity analyses should be interpreted on this background. At 10 years after injury, the mean (SD) PCS score for physical health was 41.8 (11.7), and the mean (SD) MCS score for mental health was 48.7 (10.6). There were no significant differences in the PCS and MCS scores at 10 years with
TABLE 2. Injuries to the Brain, Spine, and Extremities According to the Ulleval Trauma Registry. Patient Frequencies for the Full Sample of 105 Patients With Multiple Injuries and the 58 Participants at the 10-year Follow-Up* Full Study Population (n = 105) Body regions
Study Population at the 10-y Follow-up (n = 58)
Frequency
Specifics
Frequency
Specifics
Head
64 (61%)
34 (59%)
Spine total Extremities
41 (39%) 72 (69%)
GCS score e 9 in 28 patients (severe) GCS score 9 Y 12 in 12 patients (moderate) Spinal cord injuries: 8 incomplete, 10 complete 3 amputations, in 2 people
GCS score e 9 in 15 patients (severe) GCS score 9 Y 12 in 4 patients (moderate) Spinal cord injuries: 4 incomplete, 6 complete 3 amputation in 2 people
27 (47%) 44 (76%)
*Frequencies do not include multiple injuries in one body region. Injuries to one body region are counted once.
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TABLE 3. Functioning According to the SF-36 at 1, 2, 5, and 10 Years After Injury
Physical functioning Role physical Bodily pain General health Vitality Social functioning Role emotional Mental health Cognitive function PCS MCS
1 y After Injury
2 y After Injury
5 y After Injury
10 y After Injury
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
61.6 (30.2) 25.9 (39.2) 59.7 (27.8) 66.3 (19.8) 54.3 (20.3) 71.7 (26.4) 62.6 (39.9) 73.8 (16.8) 77.5 (20.2) 36.2 (11.1) 45.0 (11.0)
65.4 (30.2) 39.2 (39.2) 62.0 (27.8) 64.8 (19.8) 52.2 (20.3) 74.8 (26.4) 58.6 (39.9) 72.6 (16.8) 75.4 (23.3) 38.2 (11.3) 44.5 (11.5)
67.3 (29.6) 49.6 (43.7) 60.7 (25.9) 62.8 (20.6) 54.7 (19.6) 76.5 (25.1) 70.2 (40.2) 77.0 (14.8) 77.6 (20.4) 38.7 (10.9) 46.7 (10.8)
74.2 (29.1) 55.3 (42.5) 67.8 (27.4) 68.4 (24.9) 58.5 (20.4) 81.7 (22.2) 79.3 (36.3) 79.3 (16.8) 79.7 (20.6) 41.8 (11.7) 48.8 (10.7)
Mean Difference 5Y10 y (p) 6.4 4.5 7.0 5.7 4.4 5.3 8.8 2.4 1.9 2.9 2.1
Mean Difference 10 y to Adjusted Population Norm (p) j16.9 (G0.001) j30.2 (G0.001) j9.92 (0.009) j9.6 (0.002) j5.2 (0.087) j5.4 (0.077) j8.6 (0.088) j0.6 (0.765) NA j8.2 (G0.001) j1.2 (0.378)
(0.001) (0.389) (0.014) (0.022) (0.038) (0.018) (0.062) (0.131) (0.289) (0.002) (0.044)
Changes between 5 years and 10 years and functioning at 10 years on the subscales are compared with the adjusted population norm. NA, Not Applicable.
respect to brain, extremities, or spine injuries. Twenty-four people (44.8%) scored less than 40 points on the PCS, and nine (17.2%) scored less than 40 points on the MCS, which was defined as having poor health. There were statistically significant improvements in the physical and mental health from 5 years to 10 years, with increases of 2.0 points for PCS (p = 0.002) and 2.1 points for MCS (p = 0.044). With respect to physical health, 5 people (9%) had clinically significant reduction in functioning of 5 points or more, whereas 20 (35%) had clinically significant improvement. For mental health, there were 8 people (14%) with a clinically important worse mental health of 5 points, and 17 people (30%) had improved 5 points or more. There were statistically significant improvements in functioning between 5 years and 10 years for all SF-36 domains, with the exception of role functioning and mental health. Compared with the adjusted population norm, the differences were significant for the physical health scales but not for the mental health scales. The largest differences were in physical and role physical functioning, which were respectively 16.9 points (p G 0.001) and 30.2 points (p G 0.001) lower than the population norm. The participants also reported more pain (p = 0.009) and lower general health (p = 0.002) than the adjusted general Norwegian population (Table 3). The results of the regression analyses show that none of the demographic factors predicted physical or mental health at 10 years (Table 4). For MCS, the model explained 64% of the variance. The standardized A showed that an increase in approach-oriented coping, followed by vitality at 1 year, and social functioning and mental health at 2 years, were predictors of MCS at 10 years. With respect to physical health, significant predictors of PCS were physical and cognitive functioning at 1 year, bodily pain at 2 years, and change in coping. The model explained 57% of the variance.
small but significant improvements in self-reported physical and mental health from 5 years to 10 years. The differences compared with the adjusted population norms were also significant for the physical health scales. The study sheds new light on the disease burden and the complexity of factors impacting the recovery process after trauma that should serve TABLE 4. Final Adjusted Models of the Predictors for the PCS and MCS PCS MCS Standardized A Standardized A Demographic variables
Sex, man/woman Injury-related factors
Time in hospital/ rehabilitation
Functioning at 1 y
Physical functioning Vitality Cognitive function
Functioning at 2 y
Change in coping 2Y10 y Model summary
DISCUSSION This study is to our knowledge the first where initial injury severity and early postinjury functioning have been studied jointly as predictors of long-term health at 10 years in a population of patients with severe multiple injuries. There were
Age at injury
0.004 p = 0.966 0.03 p = 0.766 j0.21 p = 0.056 0.37 p = 0.001 NA
Social function
0.26 p = 0.011 NA 0.30 p = 0.005 NA
Mental health
NA
Physical functioning Bodily pain
Increase in approach-oriented coping R2 Adjusted R2 F
0.03 p = 0.762 j0.11 p = 0.202 NA NA 0.31 p = 0.008 NA NA NA
0.20 p = 0.032
0.32 p = 0.022 0.28 p = 0.043 0.18 p = 0.031
0.62 0.57 8.1 p G 0.001
0.68 0.64 17.3 p G 0.001
Standardized A’s and p values, R2, adjusted R2, and F (p value). NA, not applied/not applied in the final model.
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as guidance for rehabilitation professionals concerning issues that should be addressed. When studying the natural course of self-reported physical and mental health in the general population during a 5-year period, Hopman et al.30 found only small changes. There were improvements and decline in physical and mental health of 5 points or greater for approximately 7% to 12% of the general population, with a small trend toward decreasing HRQL over time. In the current study, 35% of the participants reported 5 points or greater of improved physical health, and 30% had improved their mental health, indicating both larger improvements and larger variations in the health changes among trauma patients.31 Considering the findings of Hopman et al., the improvement in physical health over 5 years might be relatively larger in this study than in the general population. Moreover, the decline, particularly in physical functioning, was similar to that of the study of Hopman et al. and affected only 9% of the participants. In this respect, the aging factor is similar between the general population and the patient group.30 Although there was improvement in both physical and mental health from 5 years to 10 years, this study also shows that even at 10 years after injury, the patients had worse functioning and health on the scales constituting the PCS, compared with the general population. In contrast, the mental health factors in the injured population were not lower than the adjusted population norm at 10 years. The significant improvements in vitality and social functioning from 5 years to 10 years strengthen the main findings of a normalization of mental health after severe injuries. The regression analyses of the MCS and PCS showed that the demographic factors and variables characterizing the clinical situation at the time of injury did not contribute significantly to the explained variances, contrasting with the results from other studies on outcomes after trauma.4,32 The results indicate that other factors become more important in the long-term perspective and that the value of assessing multidimensional constructs, such as HRQL, increases with time. Self-perceived functioning and positive changes in coping strategies contributed significantly to both the physical and mental health. Furthermore, physical functioning and bodily pain during the first couple of years after injury were significant predictors of PCS, as were the social and mental functioning components of MCS, thus confirming our study hypotheses. Physical functioning was the strongest contributor to the explained variance in the PCS, indicating that selfreported physical functioning in the earlier stages after injury is in itself a good predictor of long-term physical health. In accordance with previous studies, bodily pain was significantly associated with physical health.1,3,32 This result implicates that attention should be paid on the pain management also in the earlier phases of trauma rehabilitation to maximize the recovery potential.4 In the MCS model, vitality at 1 year and social and mental functioning at 2 years contributed equally to the explained variance. This suggests the importance of social functioning in the mental health after surviving trauma.33,34 The vitality scale measures both energy (fatigue) and mood that may be related to physical and mental consequences of multiple injuries.16 In addition, the lack of energy may be an element 632
of depression, which is a well-known predictor of the MCS. The result indicates that a higher capacity to be social in the earlier stages after the injury will lead to better mental health in the long term. The predictive value of mental functioning 2 years after injury is in line with other studies.32 In our previous publication, we suggested that recovery of physical and mental health after multiple injuries might not be parallel processes.5 Changes in coping strategies were significant predictors in both health models. Our findings confirm that survivors of multiple injuries have to cope with both physical and mental consequences from the injuries. Therefore, promoting active coping efforts may positively affect the patients’ recovery. In previous studies, active coping was a predictor of better HRQL, mental health, and social functioning.5,35Y37 Trauma patients’ perceived severity of the accident and appraisal of their own coping abilities predicted return to work at 3 years after injury.37 The psychological resources should be emphasized in the rehabilitation process. A more comprehensive approach to rehabilitation is needed, and issues related to vitality, social and mental functioning, and coping should be addressed more proactively.38 Disability and satisfaction with rehabilitation were significant predictors of mental health measured by the SF-12 in a follow-up study conducted more than 10 years after injury.3 Approximately 70% rated their rehabilitation as a success; however, disability and orthopedic problems accompanied by pain and reduced mobility were commonly reported. The strength of this study is its prospective longitudinal design. However, because of restrictions on the inclusion procedures from the Privacy and Data Protection Officer at OUH, the follow-up rate of 55% is somewhat low. Because of the attrition rate, we performed sensitivity analyses with high- and low-score imputations for missing PCS and MCS scores at 10 years (Supplemental Digital Content, http://links.lww.com/TA/A525). The models were still significant according to the F statistic, (all p’s G 0.001) and the direction of associations did not change substantially, indicating the robust results. However, there were some differences in the baseline characteristics between the people lost to follow-up (i.e., younger men with lower education and persons with more severe TBIs) and the study population at 10 years. The postinjury functioning measured in this study might, thus, be better than for the overall group of people with severe multiple injuries, and the difference to the general population might be larger than reported in this study. This line of reasoning is supported by the study of Gross et al. in which TBI patients fared worse than the non-TBI population.12 Patient functioning was assessed by self-report measures only, and the lack of an associated clinical examination might be considered a limitation.
CONCLUSION People who sustain severe multiple injuries have reduced physical health at 10 years after injury compared with the general population. Their mental health did not differ from the general population. The physical and mental health improved from 5 years 10 years. A higher social functioning improves mental health in the long term. Increased use of approach-oriented * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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coping strategies predicted both the physical and mental health at 10 years after injury. A more comprehensive approach should be taken for rehabilitation after multiple injuries. AUTHORSHIP H.L.S. designed the study, performed the data collection, analyzed the data, and wrote the manuscript. E.B.-H. contributed in designing the study and writing the manuscript. A.F. contributed in designing the study, and writing the manuscript. O.R. contributed in designing the study and writing the manuscript. N.A. contributed in analyzing the data and writing the manuscript.
ACKNOWLEDGMENT We would like to thank Professor Leiv Sandvik, Section of Epidemiology and Biostatistics at Oslo University Hospital, for the statistical advice.
DISCLOSURE The authors declare no conflicts of interest. This project has been financially supported by The Norwegian ExtraFoundation for Health and Rehabilitation through EXTRA funds, and The Norwegian Fund for Postgraduate Training in Physiotherapy.
REFERENCES 1. Lippert-Gruner M, Maegele M, Haverkamp H, Klug N, Wedekind C. Health-related quality of life during the first year after severe brain trauma with and without polytrauma. Brain Inj. 2007;21:451Y455. 2. Andruszkow H, Probst C, Grun O, Krettek C, Hildebrand F. Does additional head trauma affect the long-term outcome after upper extremity trauma in multiple traumatized patients: is there an additional effect of traumatic brain injury? Clin Orthop Relat Res. 2013;2899Y2905. 3. Steel J, Youssef M, Pfeifer R, et al. Health-related quality of life in patients with multiple injuries and traumatic brain injury 10+ years postinjury. J Trauma. 2010;69:523Y530. 4. Ulvik A, Kvale R, Wentzel-Larsen T, Flaatten H. Quality of life 2Y7 years after major trauma. Acta Anaesthesiol Scand. 2008;52:195Y201. 5. Soberg HL, Finset A, Roise O, Bautz-Holter E. The trajectory of physical and mental health from injury to 5 years after multiple trauma: a prospective, longitudinal cohort study. Arch Phys Med Rehabil. 2012;93:765Y774. 6. Khan F, Amatya B, Hoffman K. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. Br J Surg. 2012;99(Suppl 1):88Y96. 7. Pape HC, Probst C, Lohse R, et al. Predictors of late clinical outcome following orthopedic injuries after multiple trauma. J Trauma. 2010; 69:1243Y1251. 8. Ptacek JT, Pierce GR. Issues in the study of stress and coping in rehabilitation settings. Rehabil Psychol. 2003;48:113Y124. 9. Curran CA, Ponsford JL, Crowe S. Coping strategies and emotional outcome following traumatic brain injury: a comparison with orthopedic patients. J Head Trauma Rehabil. 2000;15:1256Y1274. 10. Vassend O, Quale AJ, Roise O, Schanke AK. Predicting the long-term impact of acquired severe injuries on functional health status: the role of optimism, emotional distress and pain. Spinal Cord. 2011;49:1193Y1197. 11. Hou WH, Liang HW, Sheu CF, Hsieh CL, Chuang HY. Return to work and quality of life in workers with traumatic limb injuries: a 2-year repeatedmeasurements study. Arch Phys Med Rehabil. 2013;94:703Y710. 12. Gross T, Schuepp M, Attenberger C, Pargger H, Amsler F. Outcome in polytraumatized patients with and without brain injury. Acta Anaesthesiol Scand. 2012;56:1163Y1174. 13. Zeckey C, Hildebrand F, Pape HC, et al. Head injury in polytrauma-Is there an effect on outcome more than 10 years after the injury? Brain Inj. 2011;25:551Y559. 14. Soberg HL, Bautz-Holter E, Roise O, Finset A. Long term multidimensional functional consequences of severe multiple injuries two years after trauma: a prospective longitudinal cohort study. J Trauma. 2007;62:461Y470. 15. Ponsford J, Draper K, Schonberger M. Functional outcome 10 years after traumatic brain injury: its relationship with demographic, injury severity, and cognitive and emotional status. J Int Neuropsychol Soc. 2008;14:233Y242.
16. Soberg HL, Finset A, Bautz-Holter E, Sandvik L, Roise O. Return to work after severe multiple injuries: a multidimensional approach on status 1 and 2 years postinjury. J Trauma. 2007;62:471Y481. 17. Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997;43:922Y925. 18. Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale 1990 Revision Update 98. Des Plaines, IL: Association for the Advancement of Automotive Medicine; 1998. 19. Finset A, Steine S, Haugli L, Steen E, Laerum E. The brief approach/ avoidance coping questionnaire: development and validation. Psychol Health Med. 2002;7:75. 20. Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol. 1986;50:992Y1003. 21. Sutherland AG, Johnston AT, Hutchison JD. The New Injury Severity Score: better prediction of functional recovery after musculoskeletal injury. Value Health. 2006;9:24Y27. 22. Prasad K. The Glasgow Coma Scale: a critical appraisal of its clinimetric properties. J Clin Epidemiol. 1996;49:755Y763. 23. MacKenzie EJ, McCarthy ML, Ditunno JF, et al. Using the SF-36 for characterizing outcome after multiple trauma involving head injury. J Trauma. 2002;52:527Y534. 24. Neugebauer E, Bouillon B, Bullinger M, Wood-Dauphinee S. Quality of life after multiple traumaVsummary and recommendations of the consensus conference. Restor Neurol Neurosci. 2002;20:161Y167. 25. Ware JE Jr, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) project. J Clin Epidemiol. 1998;51:903Y912. 26. Loge JH, Kaasa S. Short form 36 (SF-36) health survey: normative data from the general Norwegian population. Scand J Soc Med. 1998;250Y258. 27. Hann M, Reeves D. The SF-36 scales are not accurately summarised by independent physical and mental component scores. Qual Life Res. 2008;17:413Y423. 28. Angst F, Aeschlimann A, Stucki G. Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities. Arthritis Rheum. 2001;45:384Y391. 29. McCarthy ML, Dikmen SS, Langlois JA, Selassie AW, Gu JK, Horner MD. Self-reported psychosocial health among adults with traumatic brain injury. Arch Phys Med Rehabil. 2006;87:953Y961. 30. Hopman WM, Berger C, Joseph L, et al. The natural progression of healthrelated quality of life: results of a five-year prospective study of SF-36 scores in a normative population. Qual Life Res. 2006;15:527Y536. 31. Kosinski M, Zhao SZ, Dedhiya S, Osterhaus JT, Ware JE Jr. Determining minimally important changes in generic and disease-specific health-related quality of life questionnaires in clinical trials of rheumatoid arthritis. Arthritis Rheum. 2000;43:1478Y1487. 32. Ponsford J, Hill B, Karamitsios M, Bahar-Fuchs A. Factors influencing outcome after orthopedic trauma. J Trauma. 2008;64:1001Y1009. 33. Andelic N, Sigurdardottir S, Schanke AK, Sandvik L, Sveen U, Roe C. Disability, physical health and mental health 1 year after traumatic brain injury. Disabil Rehabil. 2010;32:1122Y1131. 34. Dijkers MP. Quality of life after traumatic brain injury: a review of research approaches and findings. Arch Phys Med Rehabil. 2004;85:S21YS35. 35. Tomberg T, Toomela A, Pulver A, Tikk A. Coping strategies, social support, life orientation and health-related quality of life following traumatic brain injury. Brain Inj. 2005;19:1181Y1190. 36. Sasse N, Gibbons H, Wilson L, et al. Coping strategies in individuals after traumatic brain injury: associations with health-related quality of life. Disabil Rehabil. 2014;36:2152Y2160. 37. Hepp U, Moergeli H, Buchi S, Bruchhaus-Steinert H, Sensky T, Schnyder U. The long-term prediction of return to work following serious accidental injuries: a follow up study. BMC Psychiatry. 2011;11:53. 38. Soberg HL, Bautz-Holter E, Roise O, Finset A. Mental health and posttraumatic stress symptoms 2 years after severe multiple trauma: selfreported disability and psychosocial functioning. Arch Phys Med Rehabil. 2010;91:481Y488.
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Physical and mental health 10 years after multiple trauma: A prospective cohort study Helene L. Soberg, PT, PhD, Erik Bautz-Holter, MD, PhD, Arnstein Finset, PhD, Olav Roise, MD, PhD, and Nada Andelic, MD, PhD, Oslo, Norway
BACKGROUND: People who have sustained severe multiple injuries have reduced health and functioning years after the injury. For people who have sustained severe injuries, an optimal degree of predictability in future functioning and health-related quality of life is important. The main aim was to study the impacts of demographic- and injury-related factors as well as functioning at 1 year and 2 years after injury on physical and mental health 10 years after injury. METHODS: Fifty-eight participants completed a 10-year follow-up (55.2% of all included patients). Demographic and injury severity characteristics were collected, and assessments at 1, 2, 5, and 10 years after injury were performed. Patient-reported outcome measures were the Short Form 36 (SF-36), the Brief Approach/Avoidance Coping Questionnaire, and the cognitive function scale (COG). The SF-36 Physical and Mental Component Summaries (PCS and MCS, respectively) were the main outcome variables. We performed hierarchical multiple regression analyses to assess functioning on the PCS and MCS. RESULTS: Mean (SD) age at injury was 37.8 (14.7) years, 74% were male. Mean (SD) New Injury Severity Score (NISS) was 33.7 (13.0). Mean (SD) PCS score was 41.8 (11.7). Mean (SD) MCS was 48.8 (10.7). Predictors of the PCS were change in coping from 2 years to 10 years (p = 0.032), physical functioning (p G 0.001) and cognitive functioning at 1 year (p = 0.011), as well as bodily pain at 2 years (p = 0.005). Adjusted R2 was 0.57. Predictors of the MCS were change in coping (p = 0.031), vitality (p = 0.008) at 1 year, as well as social functioning (p = 0.034) and mental health (p = 0.043) at 2 years. Adjusted R2 was 0.64. CONCLUSION: Physical health was reduced compared with the adjusted general population at 10 years after injury. The mental health did not differ from that of the general population. In addition to physical functioning, coping strategies, vitality, social functioning, and mental health should be considered in the long-term rehabilitation perspective. A more comprehensive approach should be used for rehabilitation after multiple injuries. (J Trauma Acute Care Surg. 2015;78: 628Y633. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) KEY WORDS: Follow-up studies; multiple trauma; outcomes assessment (health care); rehabilitation.
T
raumatic injuries are the most frequent cause of death and disability, particularly among the working age population.1,2 People who have sustained severe multiple injuries have reduced health and functioning years after the injury.3Y7 In addition to the reduced physical and mental health, coping strategies and other personal and injury characteristics affect the health-related quality of life (HRQL).8Y10 In a study assessing people 2 years to 7 years after injury, 80% reported a reduced quality of life, and 50% reported problems in more than one dimension on EuroQol-5D.4 In addition, anxiety and Submitted: April 18, 2014, Revised: October 30, 2014, Accepted: November 4, 2014. From the Division of Surgery and Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, (H.L.S., E.B.-H.,N.A.), and Orthopedic Department (O.R.), Oslo University Hospital, Oslo; and Faculty of Medicine, Department of Behavioural Science, Institute of Basic Medical Sciences (A.F.), and Institute of Clinical Medicine, (O.R., E.B.-H.), and Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM) (N.A.), University of Oslo, Oslo, Norway. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com). Address for reprints: Helene L. Soberg, Oslo University Hospital, Division of Surgery and Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Postbox 4956 Nydalen, 0424 Oslo, Norway; email: [email protected], [email protected]. DOI: 10.1097/TA.0000000000000541
depression were reported 4 years after severe multiple injuries or spinal cord injury.10 Better coping abilities predicted the work status of workers with extremity injuries.11 Optimism and pain predicted functional health several years after injury.10 Injury severity can have differing impact on health and functioning over time.4,7 In some studies, having a traumatic brain injury (TBI) among the injuries resulted in more disability,2,12,13 worse psychological functioning, and more chronic pain.3 In our previous publications, a history of TBI was not predictive of self-reported health and functioning.5,14 For people who have sustained severe injuries, an optimal degree of predictability in future functioning and HRQL is important. There is a paucity of research related to long-term outcome, which here is defined as up to 10 years after injury. This concerns which injury- and rehabilitation-related factors as well as aspects of functioning are associated with long-term physical and mental health.3 In addition, few studies have examined factors that predict physical and mental health 10 years or more after multiple injuries or TBI.3,15 To our knowledge, there are no prospective studies that have studied changes in physical and mental health in the long-term perspective after severe multiple injuries and the association between functioning in the postacute rehabilitation phases and functioning at 10 years. The aim of this study was to examine the physical and mental health of a cohort who sustained severe multiple injuries J Trauma Acute Care Surg Volume 78, Number 3
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10 years previously. We wanted to study the changes in health and functioning from 5 years to 10 years after injury and differences in functioning at 10 years when compared with the general population. Finally, the aim was to study which demographic and injury-related factors and functioning at 1 and 2 years, that predict health at 10 years. We hypothesized that physical functioning and pain would predict physical health and that social functioning and mental health would predict mental health at 10 years. We also assumed that a more approach-oriented coping strategy would predict both physical and mental health.
PATIENTS AND METHODS Patients This study constitutes the 10-year follow-up of patients with severe multiple injuries; it is the continuation of a prospective cohort study with follow-ups conducted upon return home and at 1, 2, and 5 years after injury. It was performed at Oslo University Hospital (OUH), Norway, a regional trauma referral center with a population base of 2.5 million inhabitants in 2002. The study population consists of patients aged 18 years to 67 years at the time of injury who were admitted to the hospital within 24 hours after the injury from January 2002 through June 2003. Patients who participated in the 10-year follow-up are included in the current study. The inclusion procedure and criteria have been previously described.16 Briefly, patients with a New Injury Severity Score (NISS) of 16 or greater and at least two injuries classified according to the Abbreviated Injury Scale (AIS) scoring system were included.17,18 The exclusion criteria were a history of multiple injuries, burn injuries, substance addiction or severe psychological disease, and malignant or progressive diseases. Only people included in the 5-year follow-up were contacted for this 10-year follow-up. One-hundred five participants were originally enrolled in the study (Fig 1); the follow-up rates were 99% and 94% at 1 year and 2 years, respectively, and 80% at 5 years. Fifty-eight people (55.2%) participated in the 10-year follow-up. The participants gave written informed consent. The Regional Committee for Medical Research Ethics approved the study (#2012/81).
Measurements The patient outcomes were assessed by self-report questionnaires. The baseline data and functioning from assessments at 1, 2, 5, and 10 years after injury are presented. We recorded the following demographic data: age, sex, education, and profession. Education was dichotomized into elementary school/high school and college/university. Profession was categorized into (1) nonphysical work/being a student, (2) physical work, and (3) receiving a disability or retirement pension or unemployed. Coping, injury severity variables, and cognitive functioning were candidate predictor variables. Coping was assessed using the Brief Approach/Avoidance Coping Questionnaire (BACQ), which has 12 items.19 The BACQ is scored from 1 (disagree completely) to 5 (agree completely). A higher score indicates use of more approach-oriented coping strategies. The BACQ has satisfactory psychometric properties.19 We evaluated
Figure 1. Flow chart of patient inclusion.
the change in coping from 2 years to 10 years.20 Internal consistency measured with Cronbach’s > was 0.64 at 2 years in our sample of 58 participants.8 Injury severity data were extracted from the trauma registry at OUH. In the AIS, injuries are graded from 1 (minor injury) to 6 (maximum injury).18 The NISS is the sum of the squared AIS scores from each of the three most severe injuries.17,21 The Glasgow Coma Scale (GCS) score ranges from 3 to 15 (no response to normal consciousness).22 Length of stay in hospital/rehabilitation institution was registered. The COG is a scale for self-reported cognitive functioning used in trauma research.23 The COG evaluates how much of the time in the past 4 weeks the respondents experienced cognitive problems. The scale range is 0 to 100 (worst to best). The main outcome was assessed by the Short Form 36 (SF-36),24 which includes self-reported physical functioning, role-physical functioning, bodily pain, general health, vitality, social functioning, role-emotional functioning, and
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TABLE 1. Demographic and Injury Characteristics for the 58 Participants at the Time of Injury Demographic and Injury Characteristics Sex, men, n (%) Age at injury, mean (SD), y Education at time of injury, n (%) e12 y (high school) 912 y (university level) Profession at the time of injury, n (%) Blue collar White collar Retired No. injuries, mean (SD) NISS, mean (SD) Head AIS score (n = 34), mean (SD) GCS score, median (IQR) Weeks in hospital/rehabilitation institution, median (IQR)
43 (74.1) 37.8 (14.7) 37 (68.3) 21 (36.2) 34 (58.6) 22 (37.9) 2 (3.4) 7.6 (3.7) 33.7 (13.0) 2.9 (1.0) 15 (8Y15) 10.4 (3.0Y14.9)
IQR, interquartile range.
mental health.25 The scale range is 0 to 100 (worst to best). Norwegian general population data based on a sample of more than 2,300 people are available.26 The eight subscales can be aggregated into the Physical Component Summary (PCS) for physical health and the Mental Component Summary (MCS) for mental health.27 The oblique (correlated) PCS and MCS scores are applied as the main outcome variables.27 We computed the respective scores based on Norwegian reference data with an online calculator accessed at http://www.sf-36.org/ nbscalc/index.shtml. The PCS and MCS scores are norm based; the population means are 50 points, and 10 points refers to 1 SD. A 5-point difference is considered a minimally important change.28 PCS and MCS scores of less than 40 points (91 SD) indicate poor health.29
Data Analysis and Statistical Analysis Descriptive statistics, including cross-tabulations with W2 tests, were used. Correlations were analyzed with the Spearman’s Q or Pearson’s r. t tests and Mann-Whitney U-test were used to compare groups. Population norms adjusted for age and sex were compared with the study population with a two-sample t test. To explore the impact of functioning at 1 year and 2 years, hierarchical linear regression analyses were performed with the PCS and MCS at 10 years as outcome variables. We applied
statistical (p e 0.1 in the univariate regression, and intercorrelation coefficients G 0.8) and clinical criteria for selecting independent variables for the regression analyses. We tested postinjury functioning at 1 year and 2 years and the change in coping strategies from 2 years to 10 years in regression models with a manual backward procedure for each step separately first. We then used the significant variables from each step in a regression analysis. For the PCS, the variables were time in hospital/rehabilitation, physical function, bodily pain, vitality, and cognitive function at 1 year and 2 years and change in coping from 2 years to 10 years. For the MCS, the variables were vitality and cognitive function at 1 year, social function and mental health at 2 years, and change in coping from 2 years to 10 years. Age and sex were added in the final models for PCS and MCS to adjust for the population heterogeneity. The SF-36 scales were ln-transformed to improve the distribution. The multicollinearity, residuals, and influential data point checks showed that the assumptions of the regression models were not violated (Cook distance [D G 0.1]; Centered Leverage value [G0.2]). All variables in the analyses had 10% or fewer missing cases. The results of the final regression models are presented with R2, adjusted R2 and F, and standardized A values. p e 0.05 was considered statistically significant. We performed sensitivity analyses and imputed the 25% and 75% quartiles for missing PCS and MCS scores to test more realistic models (Appendix). IBM SPSS 21 was used for the analyses, and we used openepi.com (http://www.openepi.com/v37/Menu/ OE_Menu.htm) to test the differences between our study population’s functioning at 10 years and the population norm.
RESULTS The mean (SD) age of the 58 participants at 10 years after injury was 47.8 (14.7) years; 74% were men. The demographic and injury characteristics are shown in Tables 1 and 2. Thirty-five percent of the participants at 10 years received disability pension. There were some differences in baseline characteristics between the participants and nonparticipants at 10 years. Individuals lost to follow-up were younger (p = 0.039), were men (p = 0.008), had lower education (p = 0.014), and had more severe TBI (p = 0.038) than the participants did. The results of the sensitivity analyses should be interpreted on this background. At 10 years after injury, the mean (SD) PCS score for physical health was 41.8 (11.7), and the mean (SD) MCS score for mental health was 48.7 (10.6). There were no significant differences in the PCS and MCS scores at 10 years with
TABLE 2. Injuries to the Brain, Spine, and Extremities According to the Ulleval Trauma Registry. Patient Frequencies for the Full Sample of 105 Patients With Multiple Injuries and the 58 Participants at the 10-year Follow-Up* Full Study Population (n = 105) Body regions
Study Population at the 10-y Follow-up (n = 58)
Frequency
Specifics
Frequency
Specifics
Head
64 (61%)
34 (59%)
Spine total Extremities
41 (39%) 72 (69%)
GCS score e 9 in 28 patients (severe) GCS score 9 Y 12 in 12 patients (moderate) Spinal cord injuries: 8 incomplete, 10 complete 3 amputations, in 2 people
GCS score e 9 in 15 patients (severe) GCS score 9 Y 12 in 4 patients (moderate) Spinal cord injuries: 4 incomplete, 6 complete 3 amputation in 2 people
27 (47%) 44 (76%)
*Frequencies do not include multiple injuries in one body region. Injuries to one body region are counted once.
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TABLE 3. Functioning According to the SF-36 at 1, 2, 5, and 10 Years After Injury
Physical functioning Role physical Bodily pain General health Vitality Social functioning Role emotional Mental health Cognitive function PCS MCS
1 y After Injury
2 y After Injury
5 y After Injury
10 y After Injury
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
61.6 (30.2) 25.9 (39.2) 59.7 (27.8) 66.3 (19.8) 54.3 (20.3) 71.7 (26.4) 62.6 (39.9) 73.8 (16.8) 77.5 (20.2) 36.2 (11.1) 45.0 (11.0)
65.4 (30.2) 39.2 (39.2) 62.0 (27.8) 64.8 (19.8) 52.2 (20.3) 74.8 (26.4) 58.6 (39.9) 72.6 (16.8) 75.4 (23.3) 38.2 (11.3) 44.5 (11.5)
67.3 (29.6) 49.6 (43.7) 60.7 (25.9) 62.8 (20.6) 54.7 (19.6) 76.5 (25.1) 70.2 (40.2) 77.0 (14.8) 77.6 (20.4) 38.7 (10.9) 46.7 (10.8)
74.2 (29.1) 55.3 (42.5) 67.8 (27.4) 68.4 (24.9) 58.5 (20.4) 81.7 (22.2) 79.3 (36.3) 79.3 (16.8) 79.7 (20.6) 41.8 (11.7) 48.8 (10.7)
Mean Difference 5Y10 y (p) 6.4 4.5 7.0 5.7 4.4 5.3 8.8 2.4 1.9 2.9 2.1
Mean Difference 10 y to Adjusted Population Norm (p) j16.9 (G0.001) j30.2 (G0.001) j9.92 (0.009) j9.6 (0.002) j5.2 (0.087) j5.4 (0.077) j8.6 (0.088) j0.6 (0.765) NA j8.2 (G0.001) j1.2 (0.378)
(0.001) (0.389) (0.014) (0.022) (0.038) (0.018) (0.062) (0.131) (0.289) (0.002) (0.044)
Changes between 5 years and 10 years and functioning at 10 years on the subscales are compared with the adjusted population norm. NA, Not Applicable.
respect to brain, extremities, or spine injuries. Twenty-four people (44.8%) scored less than 40 points on the PCS, and nine (17.2%) scored less than 40 points on the MCS, which was defined as having poor health. There were statistically significant improvements in the physical and mental health from 5 years to 10 years, with increases of 2.0 points for PCS (p = 0.002) and 2.1 points for MCS (p = 0.044). With respect to physical health, 5 people (9%) had clinically significant reduction in functioning of 5 points or more, whereas 20 (35%) had clinically significant improvement. For mental health, there were 8 people (14%) with a clinically important worse mental health of 5 points, and 17 people (30%) had improved 5 points or more. There were statistically significant improvements in functioning between 5 years and 10 years for all SF-36 domains, with the exception of role functioning and mental health. Compared with the adjusted population norm, the differences were significant for the physical health scales but not for the mental health scales. The largest differences were in physical and role physical functioning, which were respectively 16.9 points (p G 0.001) and 30.2 points (p G 0.001) lower than the population norm. The participants also reported more pain (p = 0.009) and lower general health (p = 0.002) than the adjusted general Norwegian population (Table 3). The results of the regression analyses show that none of the demographic factors predicted physical or mental health at 10 years (Table 4). For MCS, the model explained 64% of the variance. The standardized A showed that an increase in approach-oriented coping, followed by vitality at 1 year, and social functioning and mental health at 2 years, were predictors of MCS at 10 years. With respect to physical health, significant predictors of PCS were physical and cognitive functioning at 1 year, bodily pain at 2 years, and change in coping. The model explained 57% of the variance.
small but significant improvements in self-reported physical and mental health from 5 years to 10 years. The differences compared with the adjusted population norms were also significant for the physical health scales. The study sheds new light on the disease burden and the complexity of factors impacting the recovery process after trauma that should serve TABLE 4. Final Adjusted Models of the Predictors for the PCS and MCS PCS MCS Standardized A Standardized A Demographic variables
Sex, man/woman Injury-related factors
Time in hospital/ rehabilitation
Functioning at 1 y
Physical functioning Vitality Cognitive function
Functioning at 2 y
Change in coping 2Y10 y Model summary
DISCUSSION This study is to our knowledge the first where initial injury severity and early postinjury functioning have been studied jointly as predictors of long-term health at 10 years in a population of patients with severe multiple injuries. There were
Age at injury
0.004 p = 0.966 0.03 p = 0.766 j0.21 p = 0.056 0.37 p = 0.001 NA
Social function
0.26 p = 0.011 NA 0.30 p = 0.005 NA
Mental health
NA
Physical functioning Bodily pain
Increase in approach-oriented coping R2 Adjusted R2 F
0.03 p = 0.762 j0.11 p = 0.202 NA NA 0.31 p = 0.008 NA NA NA
0.20 p = 0.032
0.32 p = 0.022 0.28 p = 0.043 0.18 p = 0.031
0.62 0.57 8.1 p G 0.001
0.68 0.64 17.3 p G 0.001
Standardized A’s and p values, R2, adjusted R2, and F (p value). NA, not applied/not applied in the final model.
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as guidance for rehabilitation professionals concerning issues that should be addressed. When studying the natural course of self-reported physical and mental health in the general population during a 5-year period, Hopman et al.30 found only small changes. There were improvements and decline in physical and mental health of 5 points or greater for approximately 7% to 12% of the general population, with a small trend toward decreasing HRQL over time. In the current study, 35% of the participants reported 5 points or greater of improved physical health, and 30% had improved their mental health, indicating both larger improvements and larger variations in the health changes among trauma patients.31 Considering the findings of Hopman et al., the improvement in physical health over 5 years might be relatively larger in this study than in the general population. Moreover, the decline, particularly in physical functioning, was similar to that of the study of Hopman et al. and affected only 9% of the participants. In this respect, the aging factor is similar between the general population and the patient group.30 Although there was improvement in both physical and mental health from 5 years to 10 years, this study also shows that even at 10 years after injury, the patients had worse functioning and health on the scales constituting the PCS, compared with the general population. In contrast, the mental health factors in the injured population were not lower than the adjusted population norm at 10 years. The significant improvements in vitality and social functioning from 5 years to 10 years strengthen the main findings of a normalization of mental health after severe injuries. The regression analyses of the MCS and PCS showed that the demographic factors and variables characterizing the clinical situation at the time of injury did not contribute significantly to the explained variances, contrasting with the results from other studies on outcomes after trauma.4,32 The results indicate that other factors become more important in the long-term perspective and that the value of assessing multidimensional constructs, such as HRQL, increases with time. Self-perceived functioning and positive changes in coping strategies contributed significantly to both the physical and mental health. Furthermore, physical functioning and bodily pain during the first couple of years after injury were significant predictors of PCS, as were the social and mental functioning components of MCS, thus confirming our study hypotheses. Physical functioning was the strongest contributor to the explained variance in the PCS, indicating that selfreported physical functioning in the earlier stages after injury is in itself a good predictor of long-term physical health. In accordance with previous studies, bodily pain was significantly associated with physical health.1,3,32 This result implicates that attention should be paid on the pain management also in the earlier phases of trauma rehabilitation to maximize the recovery potential.4 In the MCS model, vitality at 1 year and social and mental functioning at 2 years contributed equally to the explained variance. This suggests the importance of social functioning in the mental health after surviving trauma.33,34 The vitality scale measures both energy (fatigue) and mood that may be related to physical and mental consequences of multiple injuries.16 In addition, the lack of energy may be an element 632
of depression, which is a well-known predictor of the MCS. The result indicates that a higher capacity to be social in the earlier stages after the injury will lead to better mental health in the long term. The predictive value of mental functioning 2 years after injury is in line with other studies.32 In our previous publication, we suggested that recovery of physical and mental health after multiple injuries might not be parallel processes.5 Changes in coping strategies were significant predictors in both health models. Our findings confirm that survivors of multiple injuries have to cope with both physical and mental consequences from the injuries. Therefore, promoting active coping efforts may positively affect the patients’ recovery. In previous studies, active coping was a predictor of better HRQL, mental health, and social functioning.5,35Y37 Trauma patients’ perceived severity of the accident and appraisal of their own coping abilities predicted return to work at 3 years after injury.37 The psychological resources should be emphasized in the rehabilitation process. A more comprehensive approach to rehabilitation is needed, and issues related to vitality, social and mental functioning, and coping should be addressed more proactively.38 Disability and satisfaction with rehabilitation were significant predictors of mental health measured by the SF-12 in a follow-up study conducted more than 10 years after injury.3 Approximately 70% rated their rehabilitation as a success; however, disability and orthopedic problems accompanied by pain and reduced mobility were commonly reported. The strength of this study is its prospective longitudinal design. However, because of restrictions on the inclusion procedures from the Privacy and Data Protection Officer at OUH, the follow-up rate of 55% is somewhat low. Because of the attrition rate, we performed sensitivity analyses with high- and low-score imputations for missing PCS and MCS scores at 10 years (Supplemental Digital Content, http://links.lww.com/TA/A525). The models were still significant according to the F statistic, (all p’s G 0.001) and the direction of associations did not change substantially, indicating the robust results. However, there were some differences in the baseline characteristics between the people lost to follow-up (i.e., younger men with lower education and persons with more severe TBIs) and the study population at 10 years. The postinjury functioning measured in this study might, thus, be better than for the overall group of people with severe multiple injuries, and the difference to the general population might be larger than reported in this study. This line of reasoning is supported by the study of Gross et al. in which TBI patients fared worse than the non-TBI population.12 Patient functioning was assessed by self-report measures only, and the lack of an associated clinical examination might be considered a limitation.
CONCLUSION People who sustain severe multiple injuries have reduced physical health at 10 years after injury compared with the general population. Their mental health did not differ from the general population. The physical and mental health improved from 5 years 10 years. A higher social functioning improves mental health in the long term. Increased use of approach-oriented * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 3
Soberg et al.
coping strategies predicted both the physical and mental health at 10 years after injury. A more comprehensive approach should be taken for rehabilitation after multiple injuries. AUTHORSHIP H.L.S. designed the study, performed the data collection, analyzed the data, and wrote the manuscript. E.B.-H. contributed in designing the study and writing the manuscript. A.F. contributed in designing the study, and writing the manuscript. O.R. contributed in designing the study and writing the manuscript. N.A. contributed in analyzing the data and writing the manuscript.
ACKNOWLEDGMENT We would like to thank Professor Leiv Sandvik, Section of Epidemiology and Biostatistics at Oslo University Hospital, for the statistical advice.
DISCLOSURE The authors declare no conflicts of interest. This project has been financially supported by The Norwegian ExtraFoundation for Health and Rehabilitation through EXTRA funds, and The Norwegian Fund for Postgraduate Training in Physiotherapy.
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* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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