A premise of the clinical practice guideline is that injury survivors may continue to experience physical and psychological challenges long after the initial event and may benefit from psychosocial evaluation and referral to appropriate treatment.


Published 12/31/2019
Terry Stanton

New CPG Weighs Psychosocial Factors in Trauma Recovery

In December 2019, the AAOS Board of Directors approved the clinical practice guideline (CPG) for Evaluation of Psychosocial Factors Influencing Recovery from Adult Orthopaedic Trauma. The guideline was jointly developed by the Academy and the Major Extremity Trauma and Rehabilitation Consortium.

The CPG (available through the OrthoGuidelines app and at orthoguidelines.org) is based on a formal systematic review of published studies regarding the evaluation of psychosocial factors influencing recovery from adult orthopaedic trauma. In addition to providing clinical practice recommendations, the guideline also highlights limitations of the current literature and areas that require further research. It addresses psychosocial factors influencing clinical, functional, and quality-of-life recovery following military or civilian adult orthopaedic trauma.

Unlike most Academy CPGs, which commonly include 10 or more individual recommendations rated by the strength of evidence supporting them, this CPG consists of a single recommendation, broken down into pertinent factors. Similar to the recently approved CPG on limb salvage versus amputation for severe traumatic lower-extremity injuries (read the article on page 28), this complex problem is not well suited to prospective, randomized clinical trials; as such, strong evidence to guide treatment recommendations often was lacking, limiting the strength of recommendations to moderate.

Factors associated with patient outcomes

It is recommended that clinicians evaluate the following factors, as they are associated with increased biopsychosocial limitations after adult orthopaedic trauma:

  • anxiety
  • post-traumatic stress disorder (PTSD)
  • depression
  • premorbid psychiatric conditions
  • smoking
  • lower education level
  • less social support
  • resilience issues (i.e., limited self-efficacy, less effective coping strategies)

The strength of the evidence supporting the recommendations is categorized as moderate—i.e., based on evidence from two or more moderate-quality studies with consistent findings recommending for or against the intervention, prognostic factor, or diagnostic test.

The CPG offers guidance to help clinicians “actively address presence of psychosocial risk factors appropriately,” the guideline development workgroup stated in the introduction. However, the group noted that the guideline did not evaluate treatment strategies for psychosocial factors.

The recommendations are based on a formal systematic review of the available literature regarding psychosocial factors influencing recovery from adult orthopaedic trauma, which was completed by AAOS staff using a rigorous, standardized process between November 2018 and July 2019.

The theoretical guidepost for the CPG was the biopsychosocial model that “recognizes that each of the major domains (biological, psychological, social) are all contributing to the recovery process and long-term outcomes following adult orthopaedic trauma.”

The workgroup noted, “The impact of traumatic injury extends far beyond the initial hospitalization,” and “injury survivors often continue to experience physical and psychological challenges for years following the initial event.” In a military combat-deployed setting, extremity trauma prevalence rates prior to Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) were significant, comprising 58 percent to 88 percent of all injuries since the Korean War. Combat operations during OEF and OIF exhibited similar numbers of extremity wounds and fractures, accounting for approximately 54 percent of all wounds.

The group noted, “Potential benefits of evaluation of psychosocial factors influencing recovery from military and civilian adult orthopaedic trauma include identification of barriers to recovery and early referral for treatment. There appears to be low risk of harm in evaluating psychosocial risk factors. Support for how best to screen/evaluate for these factors and their effects is limited and requires further study. Barriers to psychosocial evaluation include, but are not limited to, lack of resources to properly assess the risk factors and impediments to patient response (e.g., cognitive deficits and patient refusal to participate).”

The recommendations

The guideline provides a summary of the evidence that the development group discovered and considered for each of the psychosocial factors it identified. Complete reference and citation information may be found in the full CPG. An interview with Benjamin Keizer, PhD, a psychologist and the military cochair of the development workgroup, appears on page 31.


The group found that studies meeting criteria for this analysis that indicate anxiety is a factor associated with worsened biopsychosocial outcomes in orthopaedic trauma “are few,” with just one recent high-quality retrospective, observational study of 601 patients indicating that increased anxiety at six and 12 months post-injury is associated with increased anxiety and pain at 18 months and 24 months.


One high-quality study found that increased depression at six months leads to increased depression at 12 months, and increased depression at 12 months leads to increased depression at 24 months.

Premorbid psychiatric conditions

In the literature, studies have examined the relationship between premorbid psychiatric conditions and negative patient outcomes in adult orthopaedic trauma.

In those studies, premorbid psychiatric conditions included either a specific condition, including PTSD, or the presence of any psychiatric medical comorbidity.


This assessment included three low-quality articles that observed a significant relationship between smoking and negative patient outcomes, including sickness impact profile, function, mental health, and return to work. No studies found smoking to be related to positive patient outcomes.

Lower education levels

Several articles found a significant association between higher education levels and improved patient outcomes. Although the included literature was not entirely consistent in favor of higher education, no studies showed lower education levels to be related to positive outcomes.


Two moderate studies assessing varying coping strategies found that positive patient outcomes were significantly associated with more effective coping. Outcomes with significant association included quality of life, function, PTSD, mental health, and varying levels of post-traumatic growth.

Other considerations

The guideline advises that a number of other factors may be associated with greater biopsychosocial symptom intensity, magnitude of limitations, and/or diminished health-related quality of life, including:

  • age
  • body mass index
  • race
  • gender
  • low income
  • lack of employment
  • comorbidities
  • preinjury exposure to combat-related circumstances

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.


  1. Castillo RC, Wegener ST, Heins SE, et al: Longitudinal relationships between anxiety, depression, and pain: results from a two-year cohort study of lower-extremity trauma patients. Pain 2013;12:2860-6