Pain, Depression, and PTSD Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results from the METALS Study

OBJECTIVES:Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN:A retrospective cohort study. SETTING:Four U.S. military treatment facilitiesWalter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego.Patients/Participants429 United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION:Not applicable. MAIN OUTCOME MEASUREMENTS:Outcomes assessed werefunction using the Short Musculoskeletal Functional Assessment (SMFA); PTSD using the PTSD Checklist (PCL) and Diagnostic and Statistical Manual (DSM) criteria; pain using the Chronic Pain Grade (CPG) Scale. RESULTS:METALS patients without pain, depression, or PTSD, were, on average, about one Minimally Clinically Important Difference (MCID) from age and gender adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to two MCID from population norms. METALS patients with either greater levels of pain, and who experience PTSD, depression, or both, were four to six MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury (TBI)/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS:Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.