Post-traumatic growth in polytraumatized patients after 20+ years: a long-term follow-up study of 337 patients treated at a level 1 trauma center

Injury remains amongst the leading causes of death, especially in young adults [1, 2]. High impact traumas such as vehicular traffic accidents, falls from height and industrial accidents are associated with multiple injuries and negative outcomes [3]. Through the adaptation and standardization of treatment algorithms, increased use of diagnostic tools and the improvement of (road) safety precautions, complications and mortality of polytraumatized patients have decreased significantly [4, 5]. This, in turn, led to an increase in long-term consequences in survivors, such as reductions in quality of life [6, 7].

Previous studies from our group have investigated the long-term socio-economic outcomes and psychosocial sequelae of polytrauma in a cohort from a German level one trauma center [6‐12]. Functional impairment, disability, chronic pain, unemployment, financial deficits and psychological sequelae were common among these survivors of polytrauma [11]. Long-term psychiatric outcomes after polytrauma include post-traumatic stress disorder, depression and anxiety, which interfere with rehabilitation and return to self-sufficiency [9, 10].

Individuals, who experience severe stress, however, can also show signs of positive personal development, which is referred to as post-traumatic growth [13]. It was first described in 1964 and has been studied in survivors of natural disasters, interpersonal violence, cancer, and veterans [13‐16]. Research on post-traumatic growth in the field of physical injury, however, is limited and often focuses on patients with physical disability or investigates small patient cohorts over shorter periods of time [17, 18]. Understanding the manifestation of long-term post-traumatic growth in survivors of polytrauma might show considerable potential for rehabilitation.

In this long-term cohort study, we performed a survey of polytraumatized patients 20 or more years after treatment at the same level one trauma center. The aims of this study were to determine the following:

The reporting of this study is adhering to the STROBE statement [19].

Surviving a polytrauma is a devastating experience that leaves people restricted in multiple areas of their daily lives [6, 7, 11, 28]. The long-term psychological response to such severe physical injury, however, is not exclusively negative. Through our study, we were able to gain insight into long-term post-traumatic growth after polytrauma and made the following discoveries:

The expression of post-traumatic growth is positively influenced by optimism and social support as well as resilience, social status, psychological health, education and self-efficacy [23, 24, 29]. These factors also serve a predictors for outcome, rehabilitation potential, and return to work after severe physical injury [30, 31].

Our findings suggest potential for post-traumatic growth in many polytraumatized patients; therefore, identifying and fostering it might prove beneficial for outcome and emotional well-being.

While most previously conducted studies on post-traumatic growth were performed in the fields of cancer, interpersonal violence, and natural disasters, the literature on post-traumatic growth after physical injury is very limited [14‐16, 24, 29, 32‐34]. Comparing physical injury to those fields, there are notable overlaps considering physiological stress, yet there are differences in disability, employment, and chronic pain. As this plays an important role in integrating our findings in the scientific context, each finding will be discussed independently in regards to post-traumatic growth and the outcome after polytrauma.

Our findings on the role of gender concur with the previously published literature [24]. A meta-analysis of 70 studies and 16,076 patients showed a moderate effect of female gender on the expression of post-traumatic growth [32]. One possible reason for this finding is the fact that women engage in more deliberate ruminating thoughts, which can encourage reflection, increases awareness and has been shown to positively influence post-traumatic growth [24] [35]. Women also tend to utilize a more emotion-focused coping style, which is linked to greater expression of post-traumatic growth [24, 36]. In the field of physical injuries, our results are unexpectedly positive, as previous studies have shown that women tend to have worse functional outcome after major trauma, as well as a reduced quality of life, and higher incidence of depression [37, 38]. Such findings, however, are often limited by short observation periods [37]. One previous study from our group showed no significant gender-specific difference in the expression of negative psychological sequelae after 20 or more years [10]. Furthermore, another study of our cohort showed no gender-specific differences in financial, social and medical impairments between 10 and 20 years post-injury [12]. Combined, these findings suggest that the female’s approach in dealing with trauma results in the report of post-traumatic growth even years after the injury.

While there are some conflicting views on the role of marital status on post-traumatic growth, there is a clear concurrence on the beneficial role of social support [29]. In the field of accidental injuries, one study shows an association of between marital status and post-traumatic growth 18 months post-injury, matching with our results [39]. One of the aspects of our questionnaire with the most positive answers concerned “confidence in others in times of need” and about a third of patients described positive changes regarding their “relationship to others”. This concurs with other studies, which reported long lasting improvements in close relationships through post-traumatic growth [40]. As an instantaneous loss of independence, which often comes with severe injury, requires physical and emotional support, one might be more likely to develop trust in others, resulting in such lasting improvements.

Being older at the time of injury also resulted in greater levels of post-traumatic growth. Regarding acquired physical disability, a study from 2019 reported older age as a positive influence within the first year after rehabilitation [41]. This corresponds with our results regarding post-traumatic growth. A previous study from our group found younger patients suffered more severe social restrictions (reduction in number of friends) than older patients [6]. We ascribe this to long hospital stays and a long rehabilitation process limiting the contact with peers. Additionally, functional deficits or cognitive impairment might lead to exclusion from leisure activities, which is further aggravated by failing classes or having to change schools [42]. Our previous studies also showed that younger patients have more frequent financial net income losses and are more often in debt [6]. This is likely due to disability and chronic pain, which have been shown to negatively influence on socio-economic and employment status [30, 31]. Overall, younger patients are more likely to suffer financial and social consequences after a severe injury, which decrease overall contentment.

We observed higher rates of post-traumatic growth in patients that were more severely injured. Considering the socio-economic deficits and reduced quality of life associated with severe injury, these results seem counterintuitive [6, 7, 11, 28]. However, our findings concur with results from literature, which report a positive relation between the severity of trauma exposure and level of reported post-traumatic growth [43, 44]. This effect is known to be strongest if people felt a substantial danger to their life and relates well to our findings that “Realizing the worth of life” and “Not taking health for granted” are two of the aspects of our questionnaire with the most positive answers [34]. This effect might be further emphasized by the perceived physical recovery over time, which could feel more substantial in people with more severe injuries.

Long-term post-traumatic growth in polytraumatized patients is a common development, which is encouraged by female gender, being married, older age, and higher injury severity. Emphasizing social support, personal relationships, appreciation of health and self-efficacy could positively influence this development. Further research on post-traumatic growth after severe injury and interventions to encourage its development are needed.