# Presentation: 807389

## 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

## 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.

## 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

## Polytrauma Patient Description

**n = 50**

**12.6 ****(SD = 1.1)**

** **

** **

** **

** **

** **

**Mean **

**Age in Years**

** **

**28.9 ****(SD = 8.7)**

**Mean **

**Years of Education**

** **

** **

** **

** **

**Gender**

** **

** **

**Military Service Branch**

** **

**   **

**Male**

** **

**98%**

** **

**  ****Army**

** **

**40%**

**   **

**Female**

** **

**2%**

** **

**  ****Marines**

** **

**34%**

** **

** **

**  ****Navy**

** **

**18%**

**Ethnicity**

** **

** **

**  ****National Guard**

** **

**8%**

**  **

**Caucasian**

** **

**82%**

** **

** **

** **

**  **

**African**

**-**

**American**

** **

**8%**

** **

**Deployment Theater**

** **

**  **

**Hispanic**

** **

**8%**

** **

**  ****Iraq**

** **

**98%**

**  **

**American I**

**Indian**

** **

**2%**

** **

**  ****Afghanistan**

** **

**6%**

** **

** **

**  ****Other Territories**

** **

**2%**

**Marital Status**

** **

** **

** **

** **

**  ****Married**

** **

**56%**

** **

** **

**  ****Never Married**

** **

**40%**

** **

** **

**  ****Divorced**

** **

**4%**

** **

** **

** **

## Polytraumatic Injuries

- 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%*

## 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

## 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)*

## 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)*

## Polytrauma Pain Locations

- 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%** *

## Pain Related Impairments

- Recreational or physical activity: 42%
- Emotional functioning: 34%
- Social activity: 18%
- Family relationships: 18%
- Sleep: 14%
- Sexual functioning: 2%

## Mental Health Issues

- 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%*

## 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%

## Polytrauma Pain Outcomes

- Reduced prescription of opioid pain medications
*58% at admission vs 48% **at discharge*
- Increased use of NSAIDS at discharge

## Average pain intensity rating at discharge
3.7 (SD: 3.3)
This was significantly lower than the 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

*3.7 (SD: 3.3)*
*This was significantly lower than t**he 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

- Polytrauma Pain Outcomes

## 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)*

## 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)*

## 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

## 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

## 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*