Post-traumatic sleep disturbance and psychological distress after chest trauma: A five-year observational study of incidence, predictors, recovery outcomes

Table 1 Baseline demographic and clinical characteristics of the study participants (n = 128), n (%)

Variable	Value
Demographics
Age, year (mean ± SD)	48.7 ± 14.2
Male	98 (76.6)
BMI, kg/m2 (mean ± SD)	24.3 ± 3.6
Current smoker	46 (35.9)
CCI (median, IQR)	1 (0-2)
Mechanism of injury
Motor vehicle accident	80 (62.5)
Fall from height	28 (21.9)
Occupational injury	14 (10.9)
Other	6 (4.7)
Injury characteristics
ISS (median, IQR)	14 (9-21)
ISS ≥ 16	42 (32.8)
AIS thorax score (median, IQR)	3 (3-4)
Number of rib fractures (median, IQR)	4 (2-6)
Four or more rib fractures	52 (40.6)
Bilateral rib fractures	38 (29.7)
Flail chest	18 (14.1)
Associated thoracic injuries
Pneumothorax	75 (58.6)
Hemothorax	44 (34.4)
Pulmonary contusion	58 (45.3)
Sternal fracture	12 (9.4)
Treatment and hospital course
Tube drainage of the chest	68 (53.1)
Surgical rib fixation	22 (17.2)
ICU admission	41 (32.0)
ICU LOS, days (median, IQR)	5 (3-9)
Hospital LOS, days (mean ± SD)	14.8 ± 8.6

BMI: Body mass index; CCI: Charlson Comorbidity Index; ISS: Injury Severity Score; IQR: Interquartile range; AIS: Abbreviated Injury Scale; ICU: Intensive care unit; LOS: Length of stay.

Table 2 Trajectory of sleep quality and psychological measures over 12 months of follow-up, n (%)/mean ± SD

Variable	Baseline	Discharge	3 months	6 months	12 months	P value
PSQI global score	12.84 ± 3.72	9.67 ± 3.45	7.23 ± 3.18	6.14 ± 2.89	5.47 ± 2.65	< 0.001
PSQI > 5	114 (89.1)	92 (71.9)	70 (54.7)	54 (42.2)	44 (34.4)	< 0.001
HADS-A score	10.24 ± 3.86	8.56 ± 3.42	7.12 ± 3.15	6.34 ± 2.87	6.08 ± 2.74	< 0.001
HADS-A ≥ 8	86 (67.2)	72 (56.3)	52 (40.6)	42 (32.8)	37 (28.9)	< 0.001
HADS-D score	8.42 ± 3.54	7.18 ± 3.12	5.86 ± 2.78	5.24 ± 2.56	5.12 ± 2.48	< 0.001
HADS-D ≥ 8	68 (53.1)	56 (43.8)	38 (29.7)	32 (25.0)	29 (22.7)	< 0.001
IES-R total score	38.6 ± 14.2	32.4 ± 12.8	26.8 ± 11.4	23.2 ± 10.6	21.4 ± 10.2	< 0.001
IES-R ≥ 24	96 (75.0)	82 (64.1)	58 (45.3)	46 (35.9)	39 (30.5)	< 0.001
IES-R ≥ 33	72 (56.3)	51 (39.8)	34 (26.6)	26 (20.3)	23 (18.0)	< 0.001
Pain NRS score	6.8 ± 1.9	4.2 ± 1.6	2.8 ± 1.4	2.1 ± 1.2	1.6 ± 1.1	< 0.001

P values were derived from repeated measures analysis of variance or Cochran’s Q test. PSQI: Pittsburgh Sleep Quality Index; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale; IES-R: Impact of Event Scale-Revised; NRS: Numeric Rating Scale.

Table 3 Comparison between patients with and without persistent sleep disturbance at the 12-month follow-up visit, n (%)/mean ± SD

Variable	Persistent sleep disturbance (n = 44)	No persistent sleep disturbance (n = 84)	P value
Demographics
Age, years	53.2 ± 13.8	46.4 ± 14.0	0.012
Male	32 (72.7)	66 (78.6)	0.459
Injury characteristics
ISS	18.7 ± 7.2	12.4 ± 5.8	< 0.001
ISS ≥ 16	24 (54.5)	18 (21.4)	< 0.001
Number of rib fractures	5.8 ± 2.4	3.6 ± 1.9	< 0.001
Four or more rib fractures	28 (63.6)	24 (28.6)	< 0.001
Flail chest	10 (22.7)	8 (9.5)	0.037
Hospital course
ICU admission	22 (50.0)	19 (22.6)	0.002
Hospital LOS, days	18.9 ± 9.4	12.6 ± 7.2	< 0.001
Baseline psychological measures
PSQI score	14.6 ± 3.2	11.9 ± 3.6	< 0.001
IES-R score	46.8 ± 12.4	34.2 ± 13.6	< 0.001
IES-R ≥ 24	42 (95.5)	54 (64.3)	< 0.001
12-month outcomes
PSQI score	8.42 ± 2.14	3.94 ± 1.86	< 0.001
HADS-A score	9.82 ± 3.41	5.63 ± 2.18	< 0.001
HADS-D score	8.45 ± 2.97	4.82 ± 2.05	< 0.001
IES-R total score	34.6 ± 12.8	18.4 ± 9.6	< 0.001
Return to work	26 (59.1)	72 (85.7)	< 0.001
Chronic pain	32 (72.7)	26 (31.0)	< 0.001

ISS: Injury Severity Score; ICU: Intensive care unit; LOS: Length of stay; PSQI: Pittsburgh Sleep Quality Index; IES-R: Impact of Event Scale-Revised; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale.

Table 4 Univariate and multivariate logistic regression analysis of predictors for persistent sleep disturbance at 12 months after injury

Variable	Univariate OR (95%CI)	P value	Multivariate OR (95%CI)	P value
Age ≥ 50 years	2.18 (1.12-4.24)	0.022	1.68 (0.78-3.62)	0.186
Male sex	0.73 (0.32-1.67)	0.459	-	-
ISS ≥ 16	4.42 (2.18-8.96)	< 0.001	3.24 (1.58-6.64)	0.001
Rib fractures ≥ 4	4.38 (2.12-9.04)	< 0.001	2.87 (1.42-5.81)	0.003
Flail chest	2.79 (1.04-7.52)	0.042	1.42 (0.48-4.21)	0.528
Pneumothorax	1.86 (0.92-3.76)	0.084	1.24 (0.56-2.75)	0.596
Pulmonary contusion	2.14 (1.08-4.24)	0.029	1.38 (0.64-2.98)	0.412
ICU admission	3.42 (1.68-6.96)	0.001	1.56 (0.68-3.58)	0.294
Baseline IES-R ≥ 24	11.67 (3.38-40.26)	< 0.001	4.15 (1.96-8.79)	< 0.001
Baseline PSQI > 10	3.86 (1.84-8.10)	< 0.001	1.72 (0.74-4.00)	0.208

Variables with P < 0.10 in univariate analysis were entered into the multivariate model. Model performance: Area under the receiver operating characteristic curve = 0.82 (95% confidence interval: 0.74-0.89); Hosmer-Lemeshow P = 0.64. OR: Odds ratio; CI: Confidence interval; ISS: Injury Severity Score; ICU: Intensive care unit; IES-R: Impact of Event Scale-Revised; PSQI: Pittsburgh Sleep Quality Index.

Table 5 Correlation matrix between sleep quality and psychological measures at the 12-month follow-up visit

	PSQI	HADS-A	HADS-D	IES-R	Intrusion	Avoidance	Hyperarousal
PSQI	1.00
HADS-A	0.62a	1.00
HADS-D	0.58a	0.68a	1.00
IES-R total	0.67a	0.72a	0.64a	1.00
Intrusion	0.64a	0.68a	0.56a	0.92a	1.00
Avoidance	0.52a	0.58a	0.54a	0.86a	0.72a	1.00
Hyperarousal	0.71a	0.74a	0.62a	0.88a	0.78a	0.68a	1.00
Pain NRS	0.48a	0.42a	0.38a	0.44a	0.42a	0.36a	0.46a

^aP < 0.001.

PSQI: Pittsburgh Sleep Quality Index; HADS-A: Hospital Anxiety and Depression Scale-Anxiety subscale; HADS-D: Hospital Anxiety and Depression Scale-Depression subscale; IES-R: Impact of Event Scale-Revised; NRS: Numeric Rating Scale.