\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Multiple Emergency Department Encounters for Acute Musculoskeletal
Presentation with an Existing Mental Health Diagnosis}



\author[1]{Priya Arora}%
\author[2]{James Elliott}%
\author[2]{Fereshteh Pourkazemi}%
\author[2]{Roxanne Pebdani}%
\affil[1]{NSW Health}%
\affil[2]{The University of Sydney Faculty of Medicine and Health}%


\vspace{-1em}



  
  \date{June 10, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\subsubsection*{TITLE OF CASE}

{\label{title-of-case}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\textbf{Multiple Emergency Department Encounters for Acute
Musculoskeletal Presentation with an Existing Mental Health
Diagnosis}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\subsubsection*{SUMMARY}

{\label{summary}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
Reconceptualising acute Musculoskeletal (MSK) injuries with both stress-
and tissue- based factors is required to consider prior influences of
mental health disorders on acute persistent musculoskeletal pain
presentations involving an extremity. This report highlights repeated
emergency presentations for acute persistent musculoskeletal pain
involving an extremity for an individual in their 20s living with mental
health diagnoses ranging across Depression, Mood Disorders and an eating
disorder. This person also had mental health related inpatient
admissions that were not captured under the retrospective record review
for a large district hospital emergency department using the
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)
classification system. This case report attempts to demonstrate that
improving the understanding of pre-existing vulnerabilities and mental
health diagnoses may assist with informing healthcare design to develop
specialised care pathways for acute injury presentations with triage
settings.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\subsubsection*{BACKGROUND}

{\label{background}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
Acute MSK pain represents a common cause for seeking emergent health
care (1),(2). While the majority of acutely injured people should expect
to recover spontaneously, 50\% will transition from acute to chronic
pain and disability (3, 4). Data from robust clinical trials (5) and
prevalence studies have failed to enable us to adequately identify
individuals at risk of delayed recovery from MSK injury, and
interventions targeting known risk factors have yielded, at best, only
modest effects (6, 7). Furthermore, the most recent output from the
global burden of disease in 2019 suggest MSK conditions are a leading
cause of civilian years lived with disability. Alarmingly, this has not
changed since 1990, suggesting research has had little effect on
reducing the burdens of acute and chronic MSK conditions. Perhaps
critical to this long-standing problem is that research has not
generated new mechanistic knowledge into why some people recover and
others do not following their acute MSK presentation. (8). Perhaps
reconceptualising the acute MSK injury (be it a slip-and-fall, motor
vehicle collision, fracture, muscle strain affecting the spine or
extremities) as both a stress- and tissue-based injury is required to
integrate and consider how pre-existing diatheses such as mental health
disorders (9) influence the process of recovery. By identifying patients
who may be vulnerable to costly negative chronic outcomes, appropriate
early screening tools and preventative treatments can be offered to
improve clinical outcomes and avoid harmful secondary effects, such as
opioid dependency, stigma, poor return to work outcomes, withdrawal from
valued life roles, long-term reliance on ineffective and costly
management options and repeat emergency department (ED) encounters. For
example, people living with mental health conditions tend to experience
adverse physical health outcomes and significantly more medical
conditions as compared to others without a history of mental health
disorders. This is not to suggest the presence of a mental health
disorder(s) predisposes a person to a life of chronic pain following
adulthood injury requiring emergent care. While it is acknowledged that
the Emergency Department environment presents a challenge, if not a
trigger, to both busy, time-strapped, clinicians, and the patients
themselves, knowledge of pre-existing diatheses could inform and
streamline new clinical pathways for acute MSK injury on a
patient-by-patient basis. The case of a Caucasian woman in her twenties
seeking repeated ED management over a 7 year period is used to highlight
the challenges for both the patient and the healthcare providers in, and
beyond, the ED.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\subsubsection*{CASE PRESENTATION}

{\label{case-presentation}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
The repeated voluntary ED presentations (38 visits over 7 years, from
January 2015 -- February 2021) were observed to be for persistent
musculoskeletal pain, involving an extremity and upper limb pain.
Pre-existing diagnoses of Mood Disorder, Depression, and an Eating
Disorder (Anorexia Nervosa) were recorded at each ED presentation of
persistent MSK pain involving an extremity, and while considered, did
not feature in the clinical work-up. The retrospective record review was
approved by the Northern Sydney Local Health District Human Research
Ethics Committee, ethics approval number -- 2021/STE02301: SSA.
\emph{Design} Retrospective interrogation of electronic medical records
obtained from January 2015 until July 2021 capturing relevant data for
acute presentations of MSK pain intersecting with mental health
admissions over the preceding 12-month periods at a district hospital
Emergency Department. \emph{Setting} Emergency department triage
facility for a large urban district hospital serving a catchment of over
1.5 million people. \emph{Subject} A case report of an individual in
their twenties, with multiple ED presentations (38 visits) over a 7 year
period, classified by the treating ED physician/ clinicians using the
SNOMED CT system at each presentation. The SNOMED CT is defined as a
standardised, multilingual vocabulary of clinical terminology containing
more than 300,000 medical concepts used by health care providers within
the electronic exchange of clinical health information (10, 11) . The
SNOMED CT is made up of the numerical codes, known as concepts, used to
identifying clinical information. The number of concepts used are
largely if not completely dependent on the clinical setting and patient
census. In this case, the number of concepts available in a busy urban
ED with level 1 trauma status is in the thousands. The concepts are
divided into different groups such as body structure, clinical findings,
geography, location and biological products represented by different
concepts based on the complexity of the presenting condition. The
terminology classifies presentations under findings, disorders,
diagnoses and similar with individual numbers. SNOMED CT classifies
``findings'' as observations which may be objective or subjective
information from a primary source, including human observation whereas
the term ``disorder'' refers to as an abnormal clinical state and are
classified under the hierarchy of disease (10). SNOMED CT however also
tends to be subjective and have the same description while referring to
different concepts due to the ambiguity dependant on the triage (12).
The ED admission data captured the date, the patient's reason for the
visit to ED, MSK diagnosis provided at triage, and the pre-existing MH
diagnosis. Under SNOMED CT, findings refer to observations that exist at
the time of recording, while disorder suggests an abnormal and
underlying psycho-physical pathological process that remains a
vulnerability even post completion of treatment (11). As summarised in
Table 1, the repeated MSK/ acute pain related presentations observed
over the 2-year period were for persistent musculoskeletal pain
involving an extremity(11). There were multiple mental health related
admissions separate to the acute MSK pain presentation at ED over this
period recorded initially for an unspecified mood (affective) disorder,
progressing to Dysthymia/ Mood Disorder, followed by a separate
admission for Post-traumatic stress disorder (PTSD), a further mental
health admission for Dissociative convulsions, and the last captured
admission was for Anorexia Nervosa (classified under Eating Disorder/s).
Information regarding social circumstances, such as living independently
or in supported accommodation, employment or education status, social
supports both informal and formal including community mental health
services, General Practitioner and any non-governmental organisations
involvement was not available.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\subsubsection*{}

{\label{section-2}}

\subsubsection*{DISCUSSION}

{\label{discussion}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
This case study highlights the repeated presentations to a local
emergency department. The available data details at least 38 encounters
for acute MSK-related pain or injury, for a seven year period ending in
Feb 2021; remarkably, 28 of which were within one calendar year (2015).
Upper limb pain and persistent MSK pain involving an extremity were the
main reasons for ED presentation. However, no further mental health
presentations for the ED or specialist care were identified which may be
due to the type of data captured (or not) in the retrospective records.
The final mental health diagnosis provided in April 2017 reports a
first-time diagnosis of Anorexia Nervosa. It is important to note that
up to 40\% of people diagnosed with Anorexia Nervosa have comorbid
personality disorders across the Cluster B traits, which are defined by
the DSM as including impulsive behavioural patterns along with
compulsive traits (13). Existing evidence suggests that pain is
implicated in higher rates of generalised anxiety disorder (GAD),
post-traumatic stress disorder (PTSD) substance misuse and other
comorbid disorders (14) resulting in a further reduction in
functionality, recalcitrant treatment response and increased health care
costs. It appears that people living with mental health conditions
receiving inadequate treatment remain at risk of experiencing other
comorbid health conditions and it remains plausible that the repeated
acute pain/ MSK presentations observed may be due to an unrecognised
eating disorder phenotype. An improved understanding of pre-existing
vulnerabilities/resiliencies associated with repeated acute care
presentations and triage processes may inform healthcare redesign to
streamline more bespoke care pathways for people with acute MSK injury.
It is acknowledged that people living with a mental illness experiencing
concomitant physical symptoms, which in turn results in a shortened life
span, increased comorbidities, a lowering in their quality of life due
to a mix of disparity in healthcare access and utilisation (15).
Unfortunately, these physical symptoms have been largely attributed to
underlying psychiatric conditions (16). It is our belief that living
with a mental illness may lead to a delay in establishing the correct
diagnosis and intervention required to adequately address the physical
and mental signs/symptoms, which could result in an inappropriate plan
of care on discharge from the ED. Early onset mental health disorders
have shown to increase risk for lifelong adversity (17), contributing to
health inequity. There are several studies on the observations of, and
reporting on, an increasing number of young people presenting to the ED
with mental health disorders (18). The intensely stimulating environment
of the ED may prove a therapeutic challenge for an acutely injured
person with or without history of previous mental health disorders. The
trauma, distress, pain, and expectations around recovery are complex for
people living with a mental illness. Adding to this complexity are
pre-existing stress, pain, mental ill-health, and early life adversity
as all could influence the clinical course on a patient-by-patient basis
following acute injury. Such complexity can, and likely does, place
further demands on the resources within an ED workforce and resources
(19). \textbf{Limitations} The retrospective data collection is limited
over the time period captured between 1 January 2015 to 31 July 2021 at
the single ED location looking for only acute MSK pain presentations
with limited information gathering about any triggers prior to
presentation and existing supports and services. We do not have further
available information on the young person attending other hospital EDs
in addition to the district hospital ED within the catchment area,
largely, if not completely, due to a lack of communication between
hospital EMRs. Our retrospective record review data interrogated set
points in time and does not capture all the information from specific
presentations. Further, a lack of information around the methods of
classification of the data obtained at the time of presentation also
hampers the interpretation of the data collected from the retrospective
record review. This is a case report based on the retrospective study of
de-identified data and it was not possible to provide the patient's
perspective.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\subsubsection*{}

{\label{section-3}}

\subsubsection*{LEARNING POINTS/TAKE HOME
MESSAGES}

{\label{learning-pointstake-home-messages}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
Future work should aim to refine chart review data towards identifying
any patterns observed within specific groups and explore interventions
offered and the relative efficacy of these care pathways between people
living with a significant mental disorder/ illness as compared to
others. It is also important to explore unconscious bias displayed by
the clinicians while documenting the intensity of pain in the presence
of mental ill health and the capacity of the person presenting at an
emergency setting to offer appropriate interventions and discharge care
pathways. We raise this case to stimulate awareness and encourage
multidisciplinary discussion that reconceptualising acute MSK injury
event as both potentially injurious and distressing, influenced by
pre-existing vulnerabilities or resiliencies of the person and the
socioenvironmental context within which the person lives and functions.
Also, that under-recognised pre-existing psychopathology may represent
as a risk-factor for poor recovery from an MSK presentation. While
challenging, unrecognised vulnerabilities could promote multiple ED
presentations and an incomplete diagnostic and therapeutic landscape.
This single-study case followed the repeated ED admissions for recurrent
experienced by a young female person in a district hospital ED for
repeated acute MSK concerns while living with pre-existing mental health
issues.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
\subsubsection*{}

{\label{section-4}}

\subsubsection*{REFERENCES}

{\label{references}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.97\columnwidth}\raggedright\strut
1. Kahsay D.T., \& Pitk\selectlanguage{ngerman}äjärvi, M. Emergency nurses´ knowledge, attitude
and perceived barriers regarding pain Management in Resource-Limited
Settings: cross-sectional study. BMC nursing. 2019;18(56). 2. Cordell
W.H., Keene, K.K., Giles, B.K., Jones, J.B., Jones, J.H., Brizendine,
E.J. The high prevalence of pain in emergency medical care. Am J Emerg
Med. 2002;20(3):165-9. 3. Garnæs K.K., Mørkved, S., Tønne, T. et al.
Mental health among patients with chronic musculoskeletal pain and its
relation to number of pain sites and pain intensity, a cross-sectional
study among primary health care patients. BMC Musculoskelet Disord.
2022;23:1115. 4. Carroll L.J., Holm, L. W., Hogg-Johnson, S., Côté, P.,
Cassidy, J. D., Haldeman, S., et al. . Course and prognostic factors for
neck pain in whiplash-associated disorders (WAD): results of the Bone
and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated
Disorders. Phila Pa 1976; 2008. 5. DALYs GBD, Collaborators H, Murray
C.J., Barber R.M., Foreman K.J., Abbasoglu Ozgoren A., et al. Global,
regional, and national disability-adjusted life years (DALYs) for 306
diseases and injuries and healthy life expectancy (HALE) for 188
countries, 1990-2013: quantifying the epidemiological transition.
Lancet. 2015;386(10009):2145-91. 6. Sterling M., Smeets, R., Keijzers,
G., Warren, J., \& Kenardy, J. Physiotherapist-delivered stress
inoculation training integrated with exercise versus physiotherapy
exercise alone for acute whiplash-associated disorder (StressModex): a
randomised controlled trial of a combined psychological/physical
intervention. British journal of sports medicine. 2019;53((19)):1240-7.
7. Michaleff Z.A., Maher, C.G., Lin, C.W., Rebbeck, T., Jull, G.,
Latimer, J., Connelly, L., Sterling, M. Comprehensive physiotherapy
exercise programme or advice for chronic whiplash (PROMISE): a pragmatic
randomised controlled trial. . Lancet. 2014;384(9938):133-41. 8. Yeh D.,
Marthedal E. Common Presentations in Emergency Medicine. New York:
Springer Publishing Company. p. 1-93. 9. Garnås E. Perspective:
Darwinian Applications to Nutrition---The Value of Evolutionary Insights
to Teachers and Students. Advances in Nutrition. 2022;13(5):1431-9. 10.
Lee D C.R., Lau F., de Keizer N. A survey of SNOMED CT implementations.
J Biomed Inform 2013;46(1):87-96. 11. Willett D.L., Kannan, V., Chu, L.,
Buchanan, J. R., Velasco, F. T., Clark, J. D., Fish, J. S., Ortuzar, A.
R., Youngblood, J. E., Bhat, D. G., \& Basit, M. A. SNOMED CT Concept
Hierarchies for Sharing Definitions of Clinical Conditions Using
Electronic Health Record Data. Applied clinical informatics.
2018;9(3):667-82. 12. Al-Maharbi S A.A., Al Ghamdi H., Haddara M., Tolba
Y., El Kabbani A., Al Sadoun A., Pangilinan E., Joy J., Khait S.A.,
Al-Khudhairy M.W. Prevalence of depression and its association with
sociodemographic factors in patients with chronic pain: A
cross-sectional study in a tertiary care hospital in Saudi Arabia. Saudi
J Anaesth. 2018;12(3):419-25. 13. DSM V. Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. Association. AP, editor. Arlington,
VA: American Psychiatric Association Publishing; 2013. 14. Finan P.H.,
\& Smith, M. T. The comorbidity of insomnia, chronic pain, and
depression: dopamine as a putative mechanism. . Sleep Medicine Reviews.
2013;17(3):173 - 83. 15. DE Hert M., Correll, C. U., Bobes, J.,
Cetkovich-Bakmas, M., Cohen, D., Asai, I., Detraux, J., Gautam, S.,
Möller, H. J., Ndetei, D. M., Newcomer, J. W., Uwakwe, R., \& Leucht, S.
. Physical illness in patients with severe mental disorders. I.
Prevalence, impact of medications and disparities in health care. .
World psychiatry : official journal of the World Psychiatric Association
(WPA). 2011;10(1):52-77. 16. Shefer G., Henderson C., Howard L.M.,
Murray J., Thornicroft G. Diagnostic overshadowing and other challenges
involved in the diagnostic process of patients with mental illness who
present in emergency departments with physical symptoms--a qualitative
study. PLoS One. 2014;9(11). 17. Bor W., Najman, J.M., O'Callaghan,
G.M., et al. . Aggression and the development of delinquent behaviour in
children (Trends and Issues in Criminal Justice No. 207). Canberra:
Australian Institute of Criminology; 2001. 18. Reder S., Quan, L. .
Emergency mental health care for youth in Washington State: qualitative
research addressing hospital emergency departments' identification and
referral of youth facing mental health issues. Pediatr Emerg Care.
2004;20:742 - 8. 19. Dolan M.A., Fein, J.A. Committee on Pediatric
Emergency Medicine. Pediatric and adolescent mental health emergencies
in the emergency medical services system. Pediatrics.
2011;127(5):1356-66.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

\selectlanguage{english}
\FloatBarrier
\end{document}

