# Presentation: 316431

## Pain Management in the Severely Impaired Polytrauma Patient Entering Rehabilitation

- Joel Scholten, MD
- Physical Medicine and Rehabilitation
- James A. Haley Veterans Hospital
- Tampa, Florida

## The Polytrauma Rehab Center

- The four Polytrauma Rehabilitation Centers (PRC’s) are inpatient rehabilitation programs that have been treating combat related polytrauma patients since early 2003.
- The PRCs utilize 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

## The Polytrauma Patient

- Injuries to multiple areas of the body involving multiple organ systems resulting in significant functional impairment.
- The traumatic brain injury is usually the driving factor for rehabilitation.

## Traditional Rehab Team

- PM&RS Attending Physician
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Recreational Therapy
- Psychology
- Nursing
- Prosthetics
- Social Work

## Polytrauma Team Approach in Tampa

- Traditional Rehabilitation Team Plus:
*Multidisciplinary Team Rounds*
- Twice weekly multidisciplinary rounds
- Chief of PM&R and SCI, SCI and PM&R Attending, Internal Medicine, Infectious Disease, Surgery, Nursing, Infection Control, Case Managers, Utilization Review, Pain Management
- Discuss ongoing medical needs, pain management, psychosocial issues, military needs

## Polytrauma Team Approach in Tampa

*Pain Psychologist*
- Close interdependent collaboration with PM&R
*PTSD Psychologist*

## Tampa Polytrauma Pain Team

- Pain Psychologist:
*attends polytrauma medical rounds*
*comprehensive documentation of pain problems *
*serves on clinical and administrative teams*
*provides assessment and treatment services*
*offers consultative and educational services to staff** *

**Notes:**
PT, OT, RT, nursing, physicians

## Tampa Polytrauma Pain Team

- Pain Medical Management Consultation:
*pain medication and medication adjustments*
*opioid pain medication tapers*
- Pain Intervention Consultation:
*ESIs, Nerve Blocks, and Pump implantations*

**Notes:**
PT, OT, RT, nursing, physicians

## Physicians
Education
Medical assessment and treatment of pain
Chiropractics
Acupuncture
Injections
Physical and Occupational Therapy
Modalities
Therapies

*Education*
*Medical assessment and treatment of pain*
*Chiropractics*
*Acupuncture*
*Injections*
- Physical and Occupational Therapy
*Modalities*
*Therapies*

- Tampa Polytrauma Pain Team

## Nursing Staff
Assessment and treatment of pain
Education to patient and family
Psychosocial support
Recreational therapy
Diversional activities

*Assessment and treatment of pain*
*Education to patient and family*
*Psychosocial support*
- Recreational therapy
*Diversional activities*

- Tampa Polytrauma Pain Team

## Polytrauma Pain Management

- Early and continued treatment
*To minimize likelihood of chronic pain problems*
- Multidisciplinary in nature
- Behavioral
*Pain Psychologist*
*Therapists*
*Nursing*
*Family/Friends*

- Medical
*R/O and **manage causes*
*Medications*
-  Opioid reductions
-  Transfer of Rx between MTF and VA

## Multidisciplinary in nature (continued)
Interventional
Needed less frequently than meds and behavioral
ESIs, Nerve Blocks, Pump Implantations
Therapies and Modalities
PT
OT
RT
Acupuncture
Chiropractics

*Interventional*
- Needed less frequently than meds and behavioral
- ESIs, Nerve Blocks, Pump Implantations
*Therapies and Modalities*
- PT
- OT
- RT
- Acupuncture
- Chiropractics

- Polytrauma Pain Management

## Pain Assessment

- Challenging in Low Level Patients
- Utilize Family and Staff for comprehensive assessment of pain and impact on function
- Utilize descriptors to help differentiate type of pain :
**Musculoskeletal pain**	       _**NeuropathicPain**_
*	**Aching, Dull**	**	**	**sharp, electric*
*	**Throbbing**	**	**	**shooting, stabbing*

## Musculoskeletal Pain

- Spasticity
*ROM and stretching- involve family, therapists and nursing*
*Modalities- ice, heat*
*Renew current meds*
*Anti-spasticity meds- dantrolene, baclofen, tizanadine*
*Botox, Nerve Blocks*
- Contractures
*Prevention is key!  Range of Motion*
*Serial Casting and Bracing/Splints*

## Musculoskeletal Pain

- Heterotopic Ossification (H.O.)- calcification of soft tissues
*Elevated alkaline phosphatase*
*Bone scan for early diagnosis, plain films are positive once significant calcification has occurred*
*Indocin and Didronel *
*Radiation therapy can also be used*
*Surgical Resection only when H.O. is mature, usually after 18 months*

## Musculoskeletal Pain

- Fractures- missed diagnosis
- Sprains/Strains
- Dislocation/Subluxation
- Impingement
- Skin- decubitis ulcers, etc.
- Stump pain

## Musculoskeletal Pain- Treatment

- Exercise, Range of Motion, Massage
- Modalities- TENS, Ultrasound, Heat, Cold
- Topical Medications- Capsaicin, etc.
- NSAIDS
- Anti-spasticity meds- dantrolene, baclofen, tizanadine
- Narcotics
- Acupunture, Chiropractic manipulation

## Neuropathic Pain

- Peripheral Nerve/Plexus Injury
- Complex Regional Pain Syndrome/RSD
- Central Pain
- Phantom Pain

## Neuropathic Pain- Treatment

- Most medications used for treatment of Neuropathic pain do not have FDA approval for this use.
- Antidepressants
- Antiepileptic Meds
- TENS
- Modalities-Contrast Baths, etc
- Interventional Techniques- epidural injections, sympathetic blocks

## Pain due to Burns

- Initial Pain Management for Burns includes significant amount of narcotic
- During Rehab Phase monitor pain level and function, attempt to minimize need for breakthrough pain medications

## “Other” Pain

- Don’t blame pain on “the TBI”
*Cardiac pain*
*Abdominal pathology*
- Review mechanism of event and other injuries that occurred at the time of the initial event ie. Abdominal trauma, etc.

## Pain Management Goals

- Improve Comfort AND Function
- Correlate Pain Score with Function
- Minimize Cognitive Side Effects
- Avoid Poly-pharmacy
- Assess and monitor effect of intervention
- Involve the Patient and Family