Grant: Project Grant

Each year, over 12 million individuals in North America sustain a fracture of the extremity, many of which are managed operatively. However, outcomes are variable and many patients continue to experience persistent pain and disability at one-year after surgery. In a recent trial of patients with open extremity fractures, 67% of patients reported moderate to severe pain and 38% reported pain that interfered at least moderately with daily activities at one year. Data from the same trial demonstrated that patients' beliefs about recovery soon after surgery were the most powerful predictor of recovery. These findings contribute to a growing body of literature documenting the importance of psychological factors in predicting outcomes following surgery; however, to date, there are no approaches used in practice to identify, and treat, patients with psychological factors that place them at risk for poor outcomes. A large, high quality trial is needed to establish whether psychotherapy targeting unhelpful illness beliefs is effective in improving physical functioning and reducing pain after surgical fracture repair. We propose a multi-centre randomized controlled trial to evaluate the effect of cognitive behavioural therapy (CBT) versus usual care in 1,500 patients with operatively managed extremity fractures and at high risk of poor outcome due to unhelpful illness beliefs. This trial will evaluate the effect of CBT on the proportion of patients who experience persistent post-surgical pain and pain that interferes with daily activities, as well as its effect on physical and mental functioning and return to pre-injury function over one year after surgery. Targeting and modifying unhelpful beliefs through CBT may provide an effective strategy to improve outcomes among high-risk trauma patients.