Still in Search of Better Help for Psychological and Physical Recovery After Lower-Extremity Trauma

Commentary Psychological distress and pain are prevalent among survivors of musculoskeletal trauma. Cognitive-behavioral therapy (CBT) can affect depression and anxiety related to pain experienced during recovery. Unfortunately, scaling a resource-intensive intervention such as CBT and delivering it to a patient in the early stages of recovery have made it challenging to prove its effectiveness in improving physical function. The METRC group aimed to clear several logistical hurdles in delivering CBT to patients by administration of evidence-based CBT modalities remotely by a physical therapist and comparing this with an educational attention control group in a rigorously performed, multicenter, randomized controlled trial. Patients with at least 1 operatively treated extremity or a pelvic or acetabular injury were eligible for participation. In order to lessen the chances that treatment effects would be attenuated by the inclusion of patients with a minimal likelihood of adverse mental health or pain outcomes, the investigators used a high-risk threshold based on pain catastrophizing, fear of movement, and pain self-efficacy. Despite the high fidelity of delivered intervention and good follow-up, no difference was seen in the primary outcome (Patient-Reported Outcomes Measurement Information System [PROMIS] Physical Function) or any of the secondary pain or general health outcomes measured at 6 or 12 months. I am surprised at these negative findings, as are many researchers in the field of mental health recovery after traumatic injury. Despite succeeding in the implementation, the findings were null even in subgroup analyses by differing levels of compliance and follow-up. There are many potential explanations for these findings. One of the most compelling explanations is that the study sample, selected through screening for those at risk for poor coping mechanisms for dealing with subacute pain, may lack sufficient nuance to stratify patients most likely to respond to this form of CBT intervention. The participants in the study sample may be "too acute" to fully experience the added benefit of CBT beyond the health recovery habits afforded by the education control. Finally, although the impact of CBT on mental health outcomes (depression, anxiety, posttraumatic stress disorder) is better established for patients with injury, the mechanisms whereby potential therapeutic effects on pain and function are mediated by improved mental health, or affected directly, is still not known. If this intervention was successful in mitigating measurable adverse mental health outcomes, without impacting pain or physical function, would it be worthwhile? This is an important question for our patients to answer, while we continue to decipher causal mechanisms. Ultimately, the METRC group should be applauded for their efforts in testing a creative approach to targeting negative pain beliefs and behaviors with the goal of improving physical function. The quality testing regarding the fidelity of the randomized interventions and compliance with treatment demonstrate that telephone-based interventions are possible and bypass many of the barriers thought to make this target population "unreachable" with CBT-based interventions. Although we do not have an answer, we do have valuable information that will help to stratify and target patients for future interventions that improve mental and physical health recovery after musculoskeletal trauma. Much more research along these lines is necessary lest we leave our patients to their struggles with psychological distress and pain, thinking that we have done all that we can do with a surgical procedure alone.