SUPPLEMENT ARTICLE
Musculoskeletal Pain Management and Patient Mental
Health and Well-being
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Meghan K. Wally, PhD, Joseph R. Hsu, MD, and Rachel B. Seymour, PhD
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/20/2023
Summary: Orthopaedic trauma patients have high rates of
psychiatric disorders, which put them at risk for worse outcomes
after injury and surgery, including worse pain. Mental health
conditions, such as depression and anxiety, can affect the perception
of pain. Pain can also exacerbate or contribute to the development of
mental illness after injury. Interventions to address both mental
health and pain among orthopaedic trauma patients are critical.
Balancing safety and comfort amid a drug overdose epidemic is
challenging, and many clinicians do not feel comfortable addressing
mental health or have the resources necessary. We reviewed the
literature on the complex relationship between pain and mental
health and presented examples of scalable and accessible interven-
tions that can be implemented to promote the health and recovery of
our patients. Interventions described include screening for depres-
sion in the orthopaedic trauma clinic and the emergency department
or inpatient setting during injury and using a comprehensive and
evidence-based multimodal pain management regimen that blends
pharmacologic alternatives to opioids and physical and cognitive
strategies to manage pain.
Key Words: mental health, pain, orthopaedic trauma
(J Orthop Trauma 2022;36:S19–S24)
Accepted for publication July 11, 2022.
From the Department Orthopaedic Surgery, Atrium Health Musculoskeletal
Institute, Charlotte, NC.
Partial funding from a research Grant from the Centers for Disease Control
and Prevention (R01 CE003001). M. K. Wally reports funding from a
contract with Johnson & Johnson Medical Device Company unrelated to
this manuscript. M. K. Wally reports grant funding from the Centers for
Disease Control and Prevention and the Department of Defense. R. B.
Seymour reports funding from a contract with Johnson & Johnson
Medical Device Company unrelated to this manuscript. R. B. Seymour
reports grant funding from the Centers for Disease Control and Prevention
and the Department of Defense. J. R. Hsu reports funding from a contract
with Johnson & Johnson Medical Device Company, consulting fees
(Stryker, Smith and Nephew, Globus Medical), and payment for
lectures/presentations/speakers bureaus (Stryker, Smith and Nephew,
Lifesciences, Depuy/Synthes) unrelated to this manuscript. J. R. Hsu
reports grant funding from the Centers for Disease Control and
Prevention and the Department of Defense.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Meghan Wally, PhD, Department of Orthopaedic Surgery, Atrium
Health Musculoskeletal Institute, 1320 Scott Avenue, Charlotte, NC
28204 (e-mail: meghan.wally@atriumhealth.org).
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000002457
J Orthop Trauma  Volume 36, Number 10 Supplement, October 2022
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
INTRODUCTION
Orthopaedic surgeons and musculoskeletal clinicians
have become increasingly aware of the importance of mental
health in patient recovery after injury and surgery.
Orthopaedic trauma patients have rates of psychiatric disor-
ders as high as 45%,1 and patients with mental health condi-
tions have worse outcomes, including pain. At the same time,
orthopaedic surgeons have sought to minimize opioid use due
to the adverse side effects and risk for addiction. Recent
evidence has demonstrated that mental health conditions,
such as depression and anxiety, can affect the perception of
pain.2 Pain also predicts mental illness in the year after trau-
matic injury.2 Therefore, interventions to address both mental
health and pain among orthopaedic trauma patients are critical
tools for optimizing outcomes.
However, psychosocial interventions in the orthopaedic
trauma population are not widespread. From 2016 to 2018,
only 3% of abstracts presented at the Orthopaedic Trauma
Association observed mental health, and 1% reported on
substance use.1 Pain was more commonly assessed (10%).
Only 16 of 942 abstracts described interventions to address
psychosocial issues.
This article aims to review the literature on the
connections between mental health and pain and provide
examples of scalable and accessible interventions. While
comprehensive, resource intensive interventions may have
advantages, they are difficult to operationalize and sustain in
our practices and patients. Interventions in our population
need to be scalable because they apply to such a high volume
of our patients. Interventions also have to be accessible
because our patient population has a large proportion of
patients with socioeconomic challenges and those from
medically underserved areas.
Mental Health in Orthopaedic Trauma
As we previously stated, the prevalence of depression
in orthopaedic trauma patients is up to 45%, which is up to 5
times higher than in the general population.3 Preexisting psy-
chiatric conditions, pain, inability to perform normal activi-
ties, disruption of social roles, and opioid usage can
contribute to the onset of depression after traumatic injury.
It is difficult to tease out what proportion of patients experi-
enced preexisting depression versus new-onset depression
after a traumatic injury. The LEAP study excluded patients
with previously diagnosed depression; this study still found
approximately 40% had depressive symptomology up to 2
years after injury.4 Becher et al5 had similar findings of
53% with depressive symptoms during injury and 38% at a
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 Wally et al J Orthop Trauma  Volume 36, Number 10 Supplement, October 2022
9-month follow-up among orthopaedic trauma patients. Some
depression instruments include somatic questions, which can
be confounded by physical injury; however, one study found
more than a quarter of patients still had depressive sympto-
mology when removing the somatic questions.3 Finally,
depression does not seem to be correlated with injury severity
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in the literature,3,5 highlighting the importance of the biopsy-
chosocial model within musculoskeletal care.6
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There is a close relationship between anxiety, depres-
sive symptoms, and pain. Addressing anxiety and depressive
symptoms are becoming more contemporary in pain man-
agement for musculoskeletal injury.
It is appropriate to treat depression in the orthopaedic
trauma patient population regardless of etiology. Cognitive
behavioral therapy and pharmacotherapy [eg, specific seroto-
nin reuptake inhibitors (SSRIs)] are commonly used and
effective in improving the symptoms of depression.7 Other
cognitive strategies for anxiety and depressive symptom
reduction such as guided imagery and aromatherapy will be
discussed in the section on true multimodal pain management
(MPM).
Mental Health as a Risk Factor for Pain and
Poor Outcomes
Depression has been associated with many adverse
outcomes, including increased opioid consumption,8 poorer
patient-reported outcomes,9,10 higher rates of complications,11
and longer length of stay.9,10 This article will focus specifically
on pain.12
Patients with anxiety and depression report significantly
greater pain intensity.13,14 Inflammation might be one biolog-
ical pathway by which depression is associated with pain.
Depression is associated with increased levels of inflamma-
tory markers (ie, c-reactive protein, interleukin [IL]-6, and IL-
1), even among nonclinically depressed patients.15 Thus,
depression may lead to inflammation, inflammation may lead
to depression, or there may be a bidirectional pathway.15 The
causal pathway from depression to inflammation includes
elevated sympathetic and decreased parasympathetic nervous
activities and sedentary behavior.16 On the contrary, admin-
istration of inflammatory cytokines in animal models has been
shown to cause sickness behaviors resembling depression,
and prospective studies in humans have demonstrated an
association between inflammatory markers at baseline and
depressive symptoms over 5 years.17–19 Furthermore, treat-
ment with anti-inflammatories (ie, nonsteroidal anti-
inflammatory drugs and cytokine inhibitors) have antidepres-
sant treatment effects.20,21 Anxiety also has a strong associa-
tion with both physical function and pain interference,
although the causal pathway is unknown.22
Studies have demonstrated that reducing depression
severity can lead to reduction in pain.23 In addition, antide-
pressant medications have documented analgesic effects
themselves, even when the patient does not have depres-
sion.24,25 Therefore, many guidelines, including the Centers
for Disease Control and Prevention Guideline for Prescribing
Opioids for Chronic Pain,26 recommend treating patients with
depression with an antidepressant as part of a nonopioid pain
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management strategy or to complement opioids in a multi-
modal regimen. Furthermore, treating patients with depres-
sion with an antidepressant may increase the rate of
successful opioid tapering and cessation.27 Depression and
anxiety are also associated with higher rates of prolonged
opioid use, increased opioid use, and the development of
opioid use disorder,8,12–14,28–31 highlighting the need for both
effective pain control and minimization of opioid use risk in
patients with mental illness.
The evidence regarding the effect of psychiatric
treatment on depressive symptomology and other patient-
reported outcomes after orthopaedic surgery is also limited
and predominately reported in the arthroplasty literature. One
study in arthroplasty patients found that perioperative admin-
istration of a selective SSRI was associated with improved
postoperative outcomes.32 One placebo-controlled random-
ized trial of paroxetine (SSRI) given to orthopaedic trauma
patients did not demonstrate an effect on depressive sympto-
mology; however, the medication was given to all patients
regardless of a positive screening for depression.33 Still, this
study did show a positive effect on health and function overall
for the paroxetine group. Serotonin and norepinephrine reup-
take inhibitors have successfully been used in the total knee
arthroplasty patient population to improve pain, with no effect
on depression symptoms.34
Specific to the orthopaedic trauma population, 2
targeted psychosocial interventions have been developed
and tested. First, the Trauma Collaborative Care program, a
psychosocial support network including patient education,
peer visits, and coaching calls, did demonstrate a positive
effect on early patient outcomes.35 Unfortunately, there was
significant variability in utilization of the components of the
program, which may have dampened the effect. Second, the
Cognitive-Behavioral–Based Physical Therapy for Improving
Recovery after Traumatic Orthopaedic Lower-Extremity
Injury (CBPT-Trauma) study is underway with 375 patients
across 7 Level 1 trauma centers. This randomized controlled
trial will compare outcomes (physical function, pain, and
physical and mental health) among patients who receive the
CBPT-Trauma Program to patients offered educational
resources.36 Furthermore, cognitive behavioral interventions
are crucial to breaking the cycle between pain catastrophizing
and kinesiophobia, which can lead to poor physical recovery
and poor mental health.37
Pain as a Contributor to Poor Mental Health
Pain is common after orthopaedic injury and surgery
and can lead to new or worsening mental illness among
orthopaedic trauma patients.2,38 Although causation is diffi-
cult to determine, pain may be a mediator in the significant
relationship correlation between physical function and
depression among orthopaedic trauma patients because pain
is a major contributor to poor physical function during recov-
ery. Depression scores are increased among patients with
poorer physical function.3 Furthermore, pain is associated
with long-term disability, failure to return to work or activity,
and decreased satisfaction, which can negatively affect mental
well-being.39–41
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 J Orthop Trauma  Volume 36, Number 10 Supplement, October 2022
Patients with chronic pain are more likely to take longer
to reach pain resolution after surgery than other surgical
patients, and those who use opioids have higher postoperative
pain throughout recovery.42 Thus, preoperative opioid use
and chronic pain are significant risk factors for prolonged pain
and worse mental health after acute injury.
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The effect of pain on mental health is particularly
evident in elective orthopaedic patient populations, with
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patients experiencing pain relief because of total joint
arthroplasty or lumbar surgery also experiencing a reduction
in depressive symptoms and improved mental health.43–46
Scalable Solutions
Interventions including cognitive behavioral pain man-
agement, peer support networks, cognitive behavioral ther-
apy, and motivational interviewing demonstrate efficacy in
small groups of patients,35,47–49 and many surgeons and prac-
tices are unable to implement these into their practice, partic-
ularly for trauma patients. We have highlighted scalable and
accessible strategies that can be implemented to improve pain
and mental health among orthopaedic trauma patients.
Screening and Treatment for Depression in
Clinic
Orthopaedic surgeons may assume treating depression
symptoms is outside their scope of practice or training or that
they do not have the tools to address these symptoms if
identified. In fact, only 45% of surgeons indicate they are likely
to formally screen patients, and only 27% would be likely to
refer patients for psychological treatment.50 We encourage sur-
geons to use a validated screening tool to identify depressive
symptomology. Nonpsychiatrist physicians diagnose depression
with a sensitivity of 36.4% and a specificity of 83.7% without
such tools.51 The Patient Health Questionnaire (PHQ)-2 and
PHQ-9 screening tools are a validated metric for the identifica-
tion of depression symptomology.52–54 These tools can easily be
incorporated into an electronic health record software and inte-
grated into the workflow at clinic or in the hospital. A psychi-
atrist at our institution developed a treatment protocol to guide
appropriate psychiatric management based on the results of this
screening and embedded it within the electronic health record
(See Secrist et al55 for protocol).
Our institution automatically notifies Behavioral Health of
patients who screen positive, and they mail a letter and/or call
patients to offer them participation in a behavioral health
integration program. However, if the patient or healthcare
system is unable to access timely behavioral health care, the
orthopaedic surgeon can follow the protocol to initiate treatment
and transfer care to behavioral health or primary care later.
Implementation of this screening and treatment program at a
single surgeon’s clinic led to 35% of patients being identified
with moderate depression (PHQ $10) and triaged to further
care. Of those we identified and referred, 29% were already
receiving psychiatric care and an additional 16% followed up
with behavioral health care to initiate new care. This care path-
way represents an effective, scalable intervention for identifying
depression in orthopaedic trauma patients. However, healthcare
systems must have an existing behavioral health service line
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Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pain Management and Mental Health
with the capacity to handle these referrals through mail or phone
and accept new patients. As healthcare systems move toward
universal depression screening, the capacity of current behav-
ioral health infrastructure to support the demand for services will
become even more limited. Therefore, a pathway for orthopaedic
surgeons to confidently screen for and manage mild to moderate
depression in their patient populations is warranted. Orthopaedic
surgeons have the ability and opportunity to both screen and
intervene by prescribing antidepressant medications, have an
interval safety phone check after a few days, and then transfer
the pharmacological management to primary care or behavioral
health after the first month.
Screening and Treatment for Depression in
the Hospital
A similar process can be implemented in the acute care
setting. Acute care physicians do not accurately detect
depression in their patients.51,56 In studies screening adult
emergency department (ED) patients, up to 32% of patients
screened positive for depressive symptoms.56–60 Even when
screening is in place, emergency physicians are often unable
to address depression.58,61 One study found half of depressed
patients presenting to the ED reported interest in an ED-
initiated intervention for their depression.59 Routine depres-
sion screening has been described in the literature for home
health, postpartum, HIV, primary care, and cancer popula-
tions.62–65 However, routine screening in the acute care con-
text is more novel.66–70
As a component of a Centers for Disease Control and
Prevention-funded intervention (R01 CE003001) designed to
address primary and secondary prevention of opioid misuse and
abuse, we developed a pathway to screen for depression in acute
care (inpatient and EDs). To identify patients with undiagnosed
and, therefore, untreated depression, we added the PHQ-2 to the
standard admission workflow for all patients presenting for
scheduled surgery, injury, or pain-related complaint (Fig. 1). A
positive screen (defined as a cutoff score of 2) on the PHQ-2
prompts completion of the full PHQ-9. One item on the PHQ-9
does assess for suicidal ideation or self-harm. However, all our
hospitals and EDs currently screen every patient for suicidality
through the Columbia-Suicide Severity Rating Scale and have a
protocol in place to ensure suicidal patients are kept safe while in
our facility and connected to behavioral health resources. Thus,
increasing the use of the PHQ-9 does not present the risk of
identifying suicidal ideation without capacity to address this risk
FIGURE 1. Nursing task to complete PHQ screening in the
electronic health record.
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FIGURE 2. Multimodal pain alert after PHQ-9
assessment.
appropriately. For patients admitted to the hospital (inpatients) or
presenting to the ED scoring $10 (indicating moderate or major
depression), a prompt is displayed for the physician to consider
using the multimodal pain order set to manage pain appropri-
ately, while reducing risks associated with opioids in this pop-
ulation (Fig. 2). If a patient has a documented primary care
physician, the information is automatically sent through the elec-
tronic medical record to the patient’s documented primary care
provider (Fig. 3). For patients who do not have an established
primary care physician, our system established a telemedicine
platform to connect patients with necessary care and referrals.
This platform supports all our facilities and provides 24 hours a
day, 7 days a week access to health advice from a qualified
registered nurse and a resource for physicians and other care
providers for efficient coordination of patient referrals to the
necessary outpatient care and placement of patients with primary
care physician. This pathway ensures this assignment process
and the first appointment occur before the end of the initial
prescription if the patient was prescribed an antidepressant dur-
ing the encounter.
MPM
Creating pathways for opioid reduction and increased
use of multimodal strategies for pain management in the acute
care environment is critical for all patients, but especially for
patients with existing mental health conditions.
FIGURE 3. Primary care notification after PHQ-
9 assessment.
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True MPM, also referred to as balanced pain manage-
ment, is the use of multiple medications and nonpharmacologic
interventions designed to affect peripheral and or central
nervous system loci in the pain pathway.71 Benefits of this
treatment paradigm include potentiation of multiple medica-
tion effects and greater pain control without relying on any
one class of medication. MPM therefore mitigates the risk
profile of each medication, while allowing for synergistic
pain control from different classes of medication.
Successful postoperative MPM may include cognitive, phys-
ical, and pharmaceutical strategies. Cognitive strategies may
include psychotherapy, aroma therapy, music-induced anal-
gesia, and guided imagery. Physical strategies may include
cryotherapy, physical therapy, and transcutaneous nerve
stimulation. Pharmaceutical strategies may include nonste-
roidal anti-inflammatories, acetaminophen, gabapentinoids,
regional anesthesia (single injection or peripheral nerve
catheters), local injections, and opioids. Several reviews
and meta-analyses show MPM is effective periopera-
tively72–74 and in the ED setting.75 A multimodal pain path-
way was also endorsed by the Orthopaedic Trauma
Association in the 2019 clinical practice guideline for pain
management for acute musculoskeletal pain.76
In our healthcare system, a multidisciplinary team of
physicians, pharmacists, and other healthcare professionals
developed a pathway (also called an order set) built into the
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
 J Orthop Trauma  Volume 36, Number 10 Supplement, October 2022
electronic medical record to support the delivery of MPM
strategies to include pharmacologic alternatives to opioids
and physical and cognitive strategies (see Figure 1,
Supplemental Digitial Content 1, http://links.lww.com/
JOT/B798). This “multimodal order set” provides options
for selection of a range of pharmacologic options for analge-
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sia, including opioids, nonsteroidal anti-inflammatories, acet-
aminophen, and gabapentin, along with dosing guidance. In
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addition, physicians and advanced care practitioners have the
ability to order selected physical strategies, such as cryother-
apy, and cognitive modalities to include music therapy and
guided imagery through an inpatient education system deliv-
ered through television monitors in all patient rooms. In fact,
we preselected many of the cognitive and physical strategies
for pain management because these have negligible adverse
effects yet are often underappreciated and underutilized by
care teams. Patient handouts for each nonpharmaceutical
strategy and a job aid for opioid tapering based on the
Orthopaedic Trauma Association clinical practice guideline76
are available in the Supplementary Material.
CONCLUSIONS
Pain and poor mental health after orthopaedic trauma
are closely linked in a bidirectional relationship, and both are
associated with worse surgical outcomes. Therefore, inter-
ventions to assess both pain and mental health should be
prioritized by musculoskeletal clinicians. Balancing safety
and comfort in the midst of a drug overdose epidemic is
challenging, and many clinicians do not feel comfortable
addressing mental health or have the resources necessary.
Scalable interventions are available to orthopaedic trauma
surgeons and their teams that can be implemented in any
setting to promote the health and recovery of our patients.
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