Author ORCID Identifier

Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Health Sciences


Rehabilitation Sciences

First Advisor

Dr. Brian Noehren

Second Advisor

Dr. Richard Andreatta


Over 700,000 lower extremity fractures occur each year with a large portion of these patients developing adverse long-term pain and disability outcomes. Current literature indicates that 39% to 62.7% of all patients report continued pain long after traumatic lower extremity fracture. Concurrent physical limitations and reduced quality of life are common, with nearly one-third of all patients reporting pain-related disability seven years after limb threatening trauma, and approximately 50% of these patients having limitations in functional mobility and activities of daily living at long-term follow-up. These poor long-term injury-related pain and disability outcomes are alarming and require further action to detect individuals at the greatest risk for detrimental outcomes in earlier stages of recovery.

Evidence for the important association psychosocial factors carry with suboptimal long-term outcomes after traumatic injury is lacking. Previous research has demonstrated that depression, self-efficacy, pain catastrophizing, and fear of movement are associated with pain and disability outcomes. However, no research has determined the earliest clinically meaningful timeframe possible to screen for these psychosocial measures. Furthermore, much of the research has only evaluated one psychosocial measure at a time, limiting our understanding of the most salient psychosocial measures associated with patient pain and physical function outcomes. Additionally, none of the past studies have excluded individuals with a history of chronic pain, which may enhance the association psychosocial measures have with adverse outcomes. Finally, no multidimensional screening tools exist to stratify patient risk for adverse long-term outcomes.

Therefore, the purpose of this dissertation was to evaluate how multiple psychosocial measures were associated with long-term patient outcomes after surgical fixation of lower extremity fracture. All studies included in this dissertation are based on the same cohort of 122 patients who did not have a history of chronic pain and were followed through their first 12 months of recovery from surgical fixation of a lower extremity fracture. Patients completed validated measures of depression, self-efficacy, pain catastrophizing, fear of movement, and pain intensity one week, six weeks, three months, six months, and 12 months after definitive surgical fixation. At six weeks, each patient also completed the Subgroups for Targeted Treatment (STarT)-Lower Extremity Screening Tool (STarT-LE) with a retest completed one week later. At 12 months, patients completed validated, self-reported outcomes of chronic pain development, pain interference, and physical function.

The results of these studies indicate that six weeks after surgical fixation is the earliest time point psychosocial measures can be screened to determine risk for chronic pain, with large to very large effect sizes. Additionally, pain self-efficacy at six weeks was most strongly associated with chronic pain development and physical function at 12 months when accounting for depression and other important baseline variables. Pain catastrophizing at six weeks was most strongly associated with pain interference at 12 months when accounting for depression and other important baseline variables. Finally, we established the STarT-LE at six weeks as having strong reliability and predictive validity to stratify patients into low, medium, or high risk for each outcome at 12 months. The results of these studies objectively demonstrate that screening individuals with the STarT-LE, pain self-efficacy questionnaire, and pain catastrophizing scale six weeks after injury can inform the clinician with valuable information regarding the patient’s long-term prognosis.

Digital Object Identifier (DOI)

Funding Information

Funding was received from the Endowed University Professor in Health Sciences Pilot Grant January 2018 - August 2019 and the Major Extremity Trauma Research Consortium Young Investigator Award January 2019 to August 2020.

Available for download on Sunday, May 22, 2022