Persistent Pain, Physical Dysfunction and Decreased Quality of Life after Combat Extremity Vascular Trauma

Abstract: Background Combat-related extremity vascular injuries (EVI) have long-lasting impact on Iraq/Afghanistan Veterans. The purpose of this study is to describe long-term functional outcomes in Veterans with EVI using survey measures and identify modifiable factors that may be improved to reduce chronic pain and injury-related dysfunction. Methods Veterans with upper and lower EVI undergoing an initial limb salvage attempt were identified using the Department of Defense Trauma Registry and validated with chart abstraction. Surveys measured pain, Short Musculoskeletal Function Assessment (SMFA*) for self-reported bother and dysfunction, Veterans RAND 12-Item Health Survey (VR-12†) Physical and Mental Component Scores (PCS‡; MCS§) for quality of life, depression, Post-traumatic Stress Disorder (PTSD), and the potentially modifiable factors of reintegration into civilian life, resilient coping, resilience, and family functioning. Results Eighty-one patients responded with an average time since injury of 129 months (SD:31; range 67-180 months). Mechanism of injury included 64% explosions and 31% gunshot wounds; 16% of the respondents were diagnosed with moderate/severe/penetrating traumatic brain injury. Limb salvage rates were 100% and 77% for upper and lower extremities, respectively (p=0.004). Respondents screened positive for probable depression (55%) and PTSD (51%). Compared to population norms, SMFA bother and dysfunction indices were higher (worse), MCS was lower (worse) and PCS was similar. In multivariable models adjusting for age, marital status and pain, higher SMFA-bother was associated with poorer PCS and MCS. MCS decreased with difficulty reintegrating into civilian life and was positively correlated with increased resilience and resilient coping. SMFA scores were greater for patients with high pain intensity and increased 6-11 points per point increase in difficulty with civilian-life reintegration. SMFA-dysfunction was associated with better family functioning. Conclusions EVI results in significant long-term disability with lasting deficits in physical function, frequent depressive symptoms and below average self-reported quality of life. Strengthening modifiable factors including resiliency and resilient coping, and providing ongoing assistance to improve reintegration into civilian life, may ameliorate the functional disabilities and chronic pain experienced by Veterans with EVI. 1