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Screening for Acute Factors That Predict Pain Post Trauma: A Pilot Study

Screening for Acute Factors That Predict Pain Post Trauma: A Pilot Study. Allyson Browne, Kim Fong, Sudhakar Rao, Fiona Wood, Stephan Schug Royal Perth Hospital University of Western Australia. Aims. Test a model of screening for pain and psychological risk factors in a trauma setting

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Screening for Acute Factors That Predict Pain Post Trauma: A Pilot Study

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  1. Screening for Acute Factors That Predict Pain Post Trauma: A Pilot Study Allyson Browne, Kim Fong, Sudhakar Rao, Fiona Wood, Stephan Schug Royal Perth Hospital University of Western Australia

  2. Aims • Test a model of screening for pain and psychological risk factors in a trauma setting • Identify risk factors for pain and psychological outcomes following trauma

  3. Pain After Traumatic Injury • Traumatic injury has been proposed as either a causal factor or trigger of chronic pain. Buskila & Neumann (2000); Staud (2004) • More than 40% of patients with limb threatening lower extremity trauma reported clinically significant pain intensity at 7 years post trauma. Castillo et al (2006)

  4. What Predicts Persistent Pain Following Trauma? • High levels of acute & post surgical pain have been linked to increased risk of persistent pain. Gehling, et al (1999); Perkins & Kehlet (2000) • Growing consensus that chronic pain may be the result of Central Neuroplasticity. Siddall & Cousins (2004) Woolf (1995) • Converging evidence suggesting that the onset of persistent pain post trauma is independent to injury characteristics and surgical decisions Jenewein et al (2009) Castillo et al (2006) Ashburn & Fine (1989)

  5. Predicting Pain Post Trauma

  6. Trauma Pain as Distinct to CLBP • Pain experience associated with recent life or serious injury threat. • People who attribute pain symptoms to injury are more likely to view any sensation as harmful, thereby increasing anxiety and avoidance behaviour. Turk et al (1996) PTSD symptoms have been shown to predict pain symptom severity post trauma. Sterling et al (2005) Jenewein et al (2009)

  7. Linking Pain and PTSD Post Trauma • PTSD and depression occur 10 and 3 times more often respectively within 12 months of injury among Australian trauma survivors compared with community samples. O’Donnell et al (2004) • Centrality of threat-expectancy, hypervigilance, and fear avoidance is common to both pain and traumatic stress evolution.Sharp & Harvey (2001) • Stress response system dysregulation is common feature to both PTSD and fibromyalgia developing after MVA. McLean et al (2005) • Trauma patients with PTSD at 3 months post injury received less morphine than those who did not develop PTSD. Bryant et al (2009)

  8. Methods • All new trauma admissions identified with LOS > 24 hrs. • Excluded: Moderate/Severe Head Injury PTA > 24 hrs or GCS < 13 at admission Severe ETOH Dependence High Suicidal Risk Overseas or Interstate Visitor Non-English Speaking • Risk Screening within 1 Month Post Injury: Medical file review Semi-Structured Clinical Interviews Standardised self report measures

  9. Assessed for eligibility (n = 191) Excluded (n =15) Discharged from hospital (n=8) Moderate head injury (n=3) Currently actively suicidal (n = 2) Intoxicated/Withdrawal (n=1) Age < 18 years (n=1) Approached for consent (n=176) Excluded (n=27) Did not consent (n = 27) Consented and screened (n=149) Excluded(n=7) Screening not completed (n=3) Not ‘at risk’ (n = 2) Moderate head injury (n=1) Age < 18 years (n=1) Randomised (n=142) Allocated to MCC (n=69) Allocated to UC (n=73) Analysed 6 Month outcomes (n=67) Lost to follow up (n =75) Working (n=6) Remote location (n=6) Unable to contact (n=50) Discontinued (n=1) Withdrawn (n=2) Incomplete data (n=10) Recruitment Flow Chart Attrition 53% at 6 Months

  10. Screening Feasibility & Follow-Up • Approximately 11% of eligible admissions were screened within the recruitment phase. • Staffing limited to 1 part-time research assistant. • High attrition at 6 months associated with high alcohol consumption at baseline, male, younger age.

  11. Mechanism of Injury Sample Characteristics • Mean Age = 36 years (SD = 15.57) • Mean ISS = 9.65 (SD = 3.82) • Mdn LOS = 13 days (SD = 11.93) • 74% male • 20% prior psych diagnosis • 15% positive suicide risk • 81% employed

  12. Type of Injury Clinical Characteristics • 72% (n = 92) Surgery • 92 % (n = 87) GA • 4% (n = 5) Amputation • 11.7% Wound Infection • 30% ETOH related injury

  13. Baseline Pain & Psychological Factors %

  14. Baseline & 6 Month Findings • 6 Month Clinical Findings • 42% diagnosed with pain related disability by Pain Specialist. • 10% & 15% diagnosed with Depression & PTSD respectively. • 15% diagnosed with comorbid Depression & PTSD.

  15. Predicting PTSD at 6 Months *p < .05, ***p < .001 Acute psychological, pain, and alcohol use predicted 70% of the variance in PTSD symptom severity at 6 months after controlling for age, gender, and injury severity.

  16. Predicting Pain at 6 Months *p < .05 Acute psychological, pain, and alcohol use predicted 27% of the variance in pain severity at 6 months after controlling for age, gender, and injury severity.

  17. Predicting Physical Function at 6 Months *p < .05, **p<.01, ***p < .001 Acute psychological, pain, and alcohol use predicted 45% of the variance in mobility at 6 months after controlling for age, gender, and injury severity.

  18. Key Findings • A small proportion of eligible patients were screened by research staff • The prevalence of clinically significant pain and psychopathology was high at both baseline and 6 months • Standardised measures of acute pain, alcohol, and posttraumatic responses predicted variance in subsequent pain, psychological, and physical outcomes

  19. Implications • Trauma Committee of RACS refers to 2007 ANZCA ‘Guidelines on Acute Pain Management’ • ANZCA Guidelines: Regular assessment of pain during rest and activity using patient self report, regular evaluation of effectiveness of acute pain management. • Translation of the guidelines & application of research evidence in acute trauma settings?

  20. Future Directions • Larger scale prospective multi-site studies required • Standardized multidisciplinary measures of both predictors and outcomes required • Further feasibility studies required to examine implementation of pain and post trauma hospital wide screening tools • A new trauma-specific model of persistent pain evolution?

  21. Dr Allyson Browne allyson.browne@uwa.edu.au University of Western Australia

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