Trauma-informed care for injuries after intimate partner violence

Introduction:
\nIntimate partner violence (IPV) is a common cause of orthopedic injury and one of the leading causes of homicide. IPV victims seeking help for their injuries in health care are known to be at specific risk of re-abuse and even death. Still, there is little research on violence leading to IPV-related injuries, and medical professionals’ responses to IPV disclosure are not always helpful. While IPV can take place in all kinds of relationships and victims represent all genders, previous studies mostly explore injury patterns in young female victims. In addition to acute injuries, IPV leads to various adverse health outcomes, like chronic somatic and psychiatric diseases. Effects of chronic stress and a prolonged “fight or flight” mode are considered as the underlying mechanisms for these health outcomes. In gynecology and oncology, there is already evidence of IPV’s effect on medical outcomes as well, but research on IPV’s effect on orthopedic injury outcomes is lacking. Furthermore, disability and financial dependency on one’s spouse – both common results of an orthopedic injury – are among the known risk factors for IPV, and changes in relationship dynamics can lead to the escalation of abuse. It is not known, however, if rates of IPV disclosure or patterns of IPV change during injury recovery. Trauma-Informed Care recognizes the commonness of IPV and other types of past trauma and aims at reducing the extensive adverse effect of past trauma on health and wellbeing. Trauma-Informed Care also provides guidelines for patient care: Universal Trauma Precautions should be used in all patient encounters and a Trauma-Specific Approach in patients with known or suspected trauma history. 
\n This doctoral dissertation comprises of two parts. The first part of the study explores victims of IPV in traumatology emergency rooms of Helsinki. The first part of the study aimed at assessing patient profiles, injury patterns and severity, violence severity and referrals to advocacy and interventions. The second part of the study was conducted in collaboration with the McMaster University, Canada. the second part of the study aimed at assessing the rate of new IPV disclosures during recovery form a musculoskeletal injury and the effect of IPV on injury healing, return to pre-injury level of function and health-related quality of life during recovery.
\nResults:
\nIn the first part of the study, serious injuries were rare. While patients typically presented with multiple minor injuries, they had typically experienced severe violence (Danger Assessment Violence Severity score >2), and half of them had at least one risk factor for lethal re-abuse. Both female and male victims in all age groups were represented among the patient profiles, and even among the most severely injured. The DAVS score or the prevalence of risk factors for lethal re-abuse did not differ by gender or age, but there was variation in patterns of violence and injury. In our sample, 89% of IPV victims attended ERs outside common working hours, and in Primary Care, only 19% of IPV victims were referred to advocacy or intervention. Severe violence or risk factors for lethal re-abuse did not affect the frequency of referrals. 
\nIn the second part of the study, 33% of recruited female patients disclosed having experienced IPV in their lifetime during the initial appointment, and an additional 12% of the remaining 169 patients disclosed lifetime experiences of IPV during the 12-month follow-up period. Disclosure of IPV at some time point during the study was associated with lower Health-Related Quality of Life and slower return to pre-injury level of activities in an a priori analysis, but the difference vanished in a post hoc analysis that was adjusted for smoking, age, comorbidities and highest level of education. We detected no difference between the groups in complication rates or serious adverse events in this pilot sample. 
\nConclusions:
\nIn the first part of the study, it was not possible to form a profile of a typical IPV victim presenting to ER. The majority of injuries were not severe, but even life-threatening injuries were seen in all genders and age groups. IPV victims presenting to traumatology ERs are typically at high risk of re-abuse and even death, and there is an urgent need for a clear advocacy and intervention protocol. 
\nIn the second part of the study, repetitive screening for IPV led to a surprisingly high rate of IPV disclosures during the 12-month follow-up. Our results indicate that those who disclose IPV may have lower HRQL and slower return to pre-injury activities compared to other patients. The results call for further research and are encouraging for preparation of a large-scale study. The results highlight the need for Trauma-Informed Care in orthopedics and traumatology.

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