Pain problems, pain-related impairments, and emotional problems in polytrauma patients

1. Pain problems, pain-related impairments, and emotional problems in polytrauma patients Robyn L. Walker, Ph.D. Clinical Psychologist James A. Haley Veterans’ Hospital Polytrauma Rehabilitation Program Chronic Pain Rehabilitation Program

2. Pain in OIF/OEF Returnees • With higher survival rates and the large group of deployed soldiers, comes a greater number of injured who must learn to live with their new disabilities. • As expected, pain is highly prevalent among these soldiers injured in the OIF/OEF conflicts. • Given the severity and complexity of OIF/OEF combat wounds, the VA has four Polytrauma Rehabilitation Centers (PRCs) that are the primary VA receiving facilities for veterans and active duty military with polytrauma injuries.

3. Polytrauma Pain • Tampa Polytrauma Rehabilitation Center (TPRC) is an inpatient rehabilitation program that has been treating combat related polytrauma patients since early 2003 • The TPRC utilizes an interdisciplinary approach to assess and treat the entire range of impairments and needs of the combat wounded and their families • Pain assessment and management is recognized as an important component of rehabilitative care

4. Polytrauma Patient Description Mean Age in Years Mean Years of Education 12.6 (SD = 1.1) 28.9 (SD = 8.7) Gender Military Service Branch Male 98% Army 40% Female 2% Marines 34% Navy 18% Ethnicity National Guard 8% Caucasian 82% Deployment Theater African - American 8% Hispanic 8% Iraq 98% American I Indian 2% 6% Afghanistan Other Territories 2% Marital Status Married 56% Never Married 40% Divorced 4% n = 50

5. Method of Injury: IEDs: 70% Airborne shrapnel: 26% Mortar rounds: 22% Gunshot wounds: 6% Type of Injury(Average #: 3.3): TBI: 80% Closed: 22% Penetrating: 58% Ortho: 50% Soft Tissue: 48% Hearing: 48% Eye: 44% Burns: 12% Compartment syndrome: 12% Limb amputation: 12% SCI: 10% Polytraumatic Injuries

6. Cognitive Functioning • Cognitive limitations are quite common among the TPRC soldiers • Average Admission Rancho Los Amigos Scale Score was 5.2 (SD = 1.9) • 71% had Rancho scores below 7 at admission indicating moderate to severe TBI

7. Polytrauma Pain • Of the 50 records reviewed, 96% experienced > 1 pain problem during rehabilitation • Valid pain intensity ratings were obtained from 68% of those soldiers at admission • Mean: 5.6 (SD: 2.2)

8. Polytrauma Pain • Average duration of pain at admission was 83.7 days (SD: 152.7; Range: 24 - 1054) • 70% of soldiers with pain, experienced it in more than one site • Mean: 2.3 (SD: 1.4)

9. Primary Pain Location Head = 32% Leg(s) = 23% Shoulder(s) = 13% Arm(s) = 11% Hand(s) = 6% Neck = 4% Secondary Pain Location Head = 22% Low back = 16% Face = 14% Hand(s) = 14% Leg(s) = 12% Neck = 10% Abdomen = 10% Polytrauma Pain Locations

10. Pain Related Impairments • Recreational or physical activity: 42% • Emotional functioning: 34% • Social activity: 18% • Family relationships: 18% • Sleep: 14% • Sexual functioning: 2%

11. 78% received a Mental Health consult Mental Health Diagnoses PTSD: 56% Adjustment Disorder: 46% Depressive Disorder: 28% Acute Stress Disorder: 5% Substance Abuse: 5% MDD: 3% Mental Health Treatment Medication: 100% Group: 59% Individual: 49% Family: 13% Mental Health Issues

12. Polytrauma Pain Management • Medication management: 100% • Physical therapy: 40% • TENS unit: 6% • Occupational therapy: 38% • Cognitive behavioral therapy: 25% • Nerve blocks: 8% • Medication pump implantation: 4%

13. Polytrauma Pain Outcomes • Reduced prescription of opioid pain medications • 58% at admission vs 48% at discharge • Increased use of NSAIDS at discharge

14. Polytrauma Pain Outcomes • Average pain intensity rating at discharge • 3.7 (SD: 3.3) • This was significantly lower than the mean admission score [F(1,27) = 6.681, p = .015] • However, pain continues to be a problem at discharge, which puts these patients at increased risk for chronic pain problems

15. Chronic Pain Risk Factors • If pain continues after the post-acute phase, there is then risk for developing chronic pain • Approximately 30% of patients who experience acute pain progress to chronic pain (Von Korff & Saunders, 1996)

16. Chronic Pain Risk Factors • Polytrauma patients are at even greater risk for developing chronic pain problems given • Continued pain despite rehabilitation • Complex/multiple injuries • Recurrent medical procedures/surgeries • Psychosocial factors affected by the pain (Shipton et al., 2005, Sondenaa et al., 2001)

17. Clinical Implications • Pain needs to be consistently assessed, treated, and documented (at least once per shift or outpatient visit) across the continuum of rehabilitation care • Polytrauma patients are at potential risk for the development of chronic pain and CPS • Aggressive multidisciplinary pain management incorporating medical and behavioral pain specialists is needed

18. Research Implications • Evaluation of long term pain outcomes in polytrauma patients • Development and evaluation of valid pain assessment measures for cognitively impaired polytrauma patients • Development and evaluation of education or policy initiatives designed to improve the consistency of assessment and treatment across the continuum of care

19. Conclusions • Evaluation and management of pain in OIF/OEF soldiers is a challenge for the VA due to • Protracted nature of the OIF and OEF conflicts • Lengthy and multiple deployment episodes • Preponderance of blast injuries • Enhanced survival rates • Interactions between PTSD, other mood disorders • Rapid changes in and need for specialized clinical care, with a paucity of research • Long range of continuum of medical care • Need for multidisciplinary pain management