physical injury and disability - aps member groups...whiplash associated disorder (wad) whiplash is...
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Physical Injury and Disability
Professor Ian Cameron MBBS PhD (Med) FAFRM (RACP)
Professor of Rehabilitation Medicine and Head, John Walsh
Centre for Rehabilitation Research, University of Sydney;
Director of Medical Services, Royal Rehabilitation Centre Sydney;
National Health and Medical Research Council Practitioner Fellow
Monday 8 December, 2014
Recovery following traumatic injury
Rehabilitation Psychology Interest Group
Disclosures
Ian Cameron’s salary is supported by funding from:
the New South Wales Motor Accidents Authority (which is the government regulator of motor vehicle crash insurance companies) and
the National Health and Medical Research Council
Ian Cameron has research projects funded by the Australian and New South Wales governments.
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Contrasting situations
Mr A, age 56, driver of vehicle hit from behind,
developed severe neck pain, unemployed at time of
crash, eight years education
Mr B, age 38, motorcycle rider, thrown to roadway,
T10 ASIA A paraplegia, motor mechanic, ten years
education
Mr C, age 47, bicycle rider, hit by motor cycle,
severe traumatic brain injury (post traumatic amnesia
3 days), manager of division of large company, 16
years education
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Summary
Injury definition
Disability definition
Injury severity definition
Contrasting situations following injury
- Spinal cord injury
- Whiplash associated disorder
- Traumatic brain injury – moderate to severe
- [Multiple trauma (skeletal)]
Disability – predicting it
Physical / psychological dichotomy is artificial
Physical injury and Disability
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Definitions
Definitions – injury and injury severity
Injury
- Pathological change in the body due to energy transfer …. (clearly does not
apply to “psychological injury”)
Injury severity
- Abbreviated Injury Scale (AIS) – allocates a severity score to injuries in each of
six body regions
- Injury Severity Score (ISS) – the AIS score for the three most serious injuries per
body region squared and added
- New Injury Severity Score (NISS) - the AIS score for the three most serious
injuries squared and added
- Note that the injury severity scores are “threat to life” scores, but are used to
indicate injury severity
6
Langley. Inj Prev 2004;10:69-71 doi:10.1136/ip.2003.003715
http://www.trauma.org/archive/scores/iss.html
http://www.trauma.org/archive/scores/ais.html
http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/trauma%20scores/injury_severity_sc
ore.htm
Definitions - disability
Disability
- World Health Organisation
- Disabilities is an umbrella term, covering
o Impairments
o Activity limitations
o Participation restrictions
›
7
http://www.who.int/topics/disabilities/en/
http://www.who.int/classifications/icf/en/
As defined in:
International Classification of
Functioning, Disability and Health
Definitions - disability
In the context of a health condition: • Impairment is a loss or abnormality of body structure
or of a physiological or psychological function
eg. loss of a limb, loss of vision
• Activity is the execution of a task or action by an
individual at the general level,
eg. mobility, communication
• Participation is involvement in a life situation at the
specific level,
eg. walking long distances, sustaining a conversation
Disability and Functioning Theoretically
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Health condition
Body structure and function
Participation Activities
Environmental factors
Personal factors
International
Classification of
Functioning, Disability
and Health (ICF)
Incorporates a
“social model” of
disability
A World
Health
Organisation
Classification
United Nations Convention on the Rights of Persons with Disabilities
10 http://www.un.org/disabilities/documents/convention/convoptprot-e.pdf
159 countries are parties. Ratified by Australia July 2008
11
http://www.who.int/features/gall
eries/disabilities/index.html
http://www.who.int/disabilities/infographic/en/index.html
WHO Disability Action
Plan 2014- 2021
12
http://www.who.int/disabilities/world_report
/2011/en/index.html
World Report on Disability
13 http://www.who.int/disabilities/world_report/2011/en/index.html
Stephen Hawking, 1942 -
http://www.youtube.com/watch?v
=imowUYQnVSY&feature=youtu.
be
Definitions – other factors
socio-demographic factors - age, gender, education and occupation
psychological function - depression, anxiety, and low self-efficacy
pain – high initial score
16
After Scholten-Peeters et al and Kamper et al
Scholten-Peeters GGM et al. Prognostic factors of whiplash-associated disorders: a systematic review of
prospective cohort studies. Pain 2003;104: 303-322
Kamper SJ et al. Course and prognostic factors of whiplash: a systematic review and meta-analysis. Pain
2008;138: 617-629.
Definitions – other factors
compensation (Yes/No) - having an open claim or having made a claim versus no open claim or no claim made;
lawyer involved (Yes/No) - having sought or obtained legal representation versus having none;
claim type - having an open claim or having made a claim under a specific scheme jurisdiction (Workers Compensation (WC), traffic injury (including Compulsory Third Party (CTP)), health insurance, other (such as disability insurance, public liability, victims compensation);
number of sick days in prior three years;
prior claim (Yes/No);
fault (Yes/No) – making a claim under tort (fault) or no fault insurance arrangements; and
compensation at two years (Yes/No) - whether the claim was open or closed/settled at two years.
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Compensation related factors (Murgatroyd et al 2014)
Assessing disability / physical function
physical function - generic and specific measures including recovery and
disability, and physical health components of health related quality of life
measures
Examples: physical component scores of SF12, SF36; Barthel Index, Functional
Independence Measure (FIM), WHODAS 2.0
Distinct from psychological function - diagnostic based measures and
mental health components of health related quality of life measures and
pain
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After Scholten-Peeters et al and Kamper et al
Scholten-Peeters GGM et al. Prognostic factors of whiplash-associated disorders: a systematic review of
prospective cohort studies. Pain 2003;104: 303-322
Kamper SJ et al. Course and prognostic factors of whiplash: a systematic review and meta-analysis. Pain
2008;138: 617-629
http://www.who.int/classifications/icf/whodasii/en/
Contrasting situations after injury
Whiplash Associated Disorder (WAD)
Whiplash is an acceleration – deceleration mechanism of energy transfer
to the neck …
The impact may result in bony or soft-tissue injuries (whiplash injury)
which in turn may lead to a variety of clinical manifestations (whiplash
associated disorders).
Mr A, age 56, severe neck pain, limited education
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Quebec Taskforce Spine 20 (8S) 1995
Neck pain - Recovery Guideline
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Systematic review – whiplash associated disorders
High quality review
“Data regarding the prognostic
factors associated with poor
recovery were difficult to interpret
…”
60% recovered at 12 months
? 70% recovered at 5 years, ie no
significant disability
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Kamper (2008)
Kamper et al. Course and prognostic factors of whiplash: a systematic review and meta-
analysis. Pain 138 (2008) 617–629.
Systematic review – whiplash associated disorders
23
Kamper et al. Course and prognostic factors of whiplash: a systematic review
and meta-analysis. Pain 138 (2008) 617–629.
Kamper (2008)
Spinal Cord Injury
Level – neck (cervical) tetraplegia, back (thoracic and lumbar) paraplegia
Completeness of injury – American Spinal Injury Association (ASIA)
classification. A – complete, B to D incomplete
Mr B, 38 yo, T10 ASIA A paraplegia, trade qualifications
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http://www.asia-spinalinjury.org/elearning/ISNCSCI.php
Al-Habib et al J Neurotrauma 2011;28:1431–1443
Spinal Cord Injury – Support Guideline
Support needs well defined
Equipment guidelines available
25
http://www.lifetimecare.nsw.gov.au/FileHandler.a
shx?name=Guidelines%20for%20Professionals/
guidelines_for_levels_of_attendant_care_for_pe
ople_with_spinal_cord_injury_pdf[doc]
Spinal cord injury – does support help?
Cohort study
People with spinal cord injury in New Zealand
Comparison between people covered by universal injury insurance
scheme and those not
Better return to work and less poverty in those covered by insurance
Health related quality of life similar
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Paul et al (2013)
Paul et al. Socioeconomic outcomes following spinal cord injury and
the role of no-fault compensation: longitudinal study. Spinal Cord (2013) 51, 919–925
Traumatic brain injury
Heterogeneous injury
Variable outcome
Initial Glasgow coma score
and duration of post
traumatic amnesia best
indicators of outcome
Mr C, 47 yo, severe injury (PTA 3 days), high level of education
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Unfavourable outcome =
dead, vegetative, poor
outcome on Glasgow
outcome scale (assistance
with self care)
http://www.trialscoordinatingcentre.lshtm.ac.uk/Risk%20calculator/index.html
Traumatic brain injury
Note strong negative effect
of increasing age
Mr C, 47 yo, severe injury (PTA 3 days), high level of education
28
http://www.trialscoordinatingcent
re.lshtm.ac.uk/Risk%20calculato
r/index.html
Other approaches to predictors of disability (excluding psychological factors) - Injury severity
Does severity of injury matter?
Large cohort in New Zealand, ages 18 to 64 years
Comparison of hospitalised and non hospitalised participants
Prevalence of disability, at 24 months, 13% in both groups
Multivariable analyses
Injury severity (as measured by New Injury Severity Score
(NISS)) NOT predictive
“There was no evidence to suggest a relationship existed between
anatomical severity of injury and risk of disability for either the hospitalised
or non-hospitalised group”.
It is the person, not the injury, influencing recovery (not in
catastrophic injury)
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Derrett et al 2013 – Prospective Outcomes of Injury Study
Derrett et al PLoS ONE 2013 8(11): e80194. doi:10.1371/journal.pone.0080194
Predicting Disability
Predictors of disability in general injury cohorts
32
Disability outcome measure was WHODAS – World Health Organisation
Disability Assessment Scale (disabled if WHODAS > 9)
Assessed disability in both hospitalised and non hospitalised people (25%
hospitalised)
28 predictor variables considered, note 91% participants were in paid work
Derrett et al PLoS ONE 2013 8(11): e80194. doi:10.1371/journal.pone.0080194
Predictors of disability in general injury cohorts
Both hospitalised and non hosp
- pre-injury disability
- two or more pre-injury chronic
conditions
- pre-injury BMI >30
- trouble accessing healthcare services
- marginal effects – age and cigarette
smoking
Hospitalised
- non optimism
- perceived threat of long term disability
Non hospitalised
- Depressive episode pre injury
- Intentional injury
Derrett et al 2013 – Prospective Outcomes of Injury Study
33
Derrett et al PLoS ONE 2013
8(11): e80194.
doi:10.1371/journal.pone.0080
194
Predictors of disability in general motor vehicle injury cohorts
Recruited from insurance regulator database, mean 8 weeks after injury
Followed to 2 years after injury (n= 247)
Independent predictors of return to usual activities (ie participation)
- Age <45yrs 1.21 (1.03-1.42)
- SF 12 physical component score (per SD increase) 1.25 (1.13-1.38)
- Marginally significant – female gender, health related quality of life (EQ 5D)
global rating
- Educational level was significant at 12 months (not 24 months)
NSW Cohort, compensable motor vehicle injuries – return to usual activities as outcome
34
Gopinath et al. Injury 2014: under review
Other approaches to predictors of disability (excluding psychological factors) - Age (and gender)
Effect of Age and gender – general injury example
36
New Zealand Prospective Outcomes of Injury Study (POIS)
n = 2856, Status 3 months after injury, adjusted for pre injury health status
Langley et al. Health and Quality of Life Outcomes 2011, 9:68
http://www.hqlo.com/content/9/1/68
Older age and female gender is associated with poorer
health related quality of life in multiple domains
Conclusion
Older age does have a negative effect on
health, disability and recovery
However, this varies with injury type (and
severity)
Female gender is associated with disability in
a number of studies
(note female gender is associated with higher
population prevalence of disability, particularly
in older people) 37
Other approaches to predictors of disability (excluding psychological factors) - Compensation status
The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review
Aim: To identify compensation related factors associated with poorer
health outcomes following musculoskeletal injury
Methods: Wide search strategy, prospective studies, prognostic factors
associated with validated health outcomes, six or more months follow up,
and multivariate statistical analysis. Excluded if return to work was only
outcome. Synthesis and assessment using GRADE methodology to
determine evidence levels.
Results: n=29 – mixed results
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Murgatroyd DF, Casey PP, Cameron ID, Harris IA. PLOS One 2014: accepted (provisionally) October 2014.
The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review
Results:
Strong evidence
association between compensation status and poorer psychological function
legal representation and poorer physical function .
Moderate evidence
association between compensation status and poorer physical function
Limited evidence
association between compensation status and increased pain
In seven studies the association depended on the outcome measured
No studies reported an association between compensation related factors and improved health outcomes
40
Murgatroyd DF, Casey PP, Cameron ID, Harris IA. PLOS One 2014: accepted provisionally October 2014.
The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review
Further research is needed to find plausible reasons why compensation
related factors are associated with poorer health following musculoskeletal
injury
Associations seem stronger for psychological health compared with
physical health and pain
These findings lend weight to the apparent influence of compensation
systems on poor psychological function particularly in the presence of poor
baseline health measures
The evidence of whether this association is causal is less certain and
further research is required. There is a definite need to compare baseline
characteristics of compensable and non-compensable study populations
Challenges ….
41
Conclusions
Murgatroyd DF, Casey PP, Cameron ID, Harris IA. PLOS One 2014: accepted provisionally
October 2014.
Cameron et al (2008)
Pre Post comparison following “natural experiment” of legislative change in
New South Wales, Australia
Legislative change reduced access to compensation for non economic
loss, capped legal fees and introduced treatment guidelines for whiplash
Disability and pain improved after legislative change
“Design of compensation schemes should be undertaken with the
understanding that the scheme structure may have substantial effects on
the long-term health of injured people
42
Legislative Change Is Associated With Improved Health Status in People
With Whiplash
Cameron et al. Spine 2008; 33: 250–254
Conceptual approach to disability following injury
International Classification of Functioning,
Disability and Health (ICF, 2001)
Health Condition (disorder or disease)
Body Function
and Structure
Activities
Environment Factors
Participation
Personal factors
http://www.who.int/classifications/icf/en/
Concepts of disability
ICF might be better, noting the breadth of environmental factors
However, some confusion in ICF between personal factors and body
function in the psychological sphere
Is biopsychosocial sufficient?
45
Future directions
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More research ?
The FISH Study
The study investigates the potential factors that may influence health and social recovery, following land transport crashes
These include:
pre- injury socio-demographic and health characteristics
injury characteristics
utilisation of health services
compensation factors such as claims process, treatment, liability and fault, and legal representation
Ultimate aim is to develop intervention studies – at a personal and societal level
Jagnoor et al. BMC Public Health 2014, 14:199 doi:10.1186/1471-2458-
14-199
Physical Injury and Disability
Examine disability from broad perspective
Recognise that there are a large number of interacting factors influencing
disability
In an injury context consider:
- Pre- injury status – health and disability
- Personal factors – age, gender, education, beliefs
- Injury details (to some extent)
- Environmental factors – family, social supports, context (including compensation)
- Treatment factors
Potentially target “treatment” to people at higher risk of disability
Future directions
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