Pain in Patients with Polytrauma 

APPENDIX A. SEARCH STRATEGY 

Two librarians (AH and RC) independently designed search strategies based on the key questions.  The

results of both searches were combined into a single reference library.   

Below is the search strategy designed by AH:  

Database: Ovid MEDLINE(R) <1950 to January Week 5 2008>

Search Strategy:

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 

1     polytraum$.mp. (2115)

2     exp Multiple Trauma/ (7404)

3     (multiple adj3 (wound$ or injur$ or traum$ or casualt$)).mp. (12171)

4     1 or 2 or 3 (13048)

5     exp Blast Injuries/ (1862)

6     exp Brain Injuries/ (34104)

7     ((head or crani$ or cereb$ or brain$ or explosi$ or explod$ or blast$) adj3 (traum$ or wound$ or injur$

or damag$)).mp. (88531)

8     5 or 6 or 7 (90818)

9     exp pain/ (218224)

10     exp pain measurement/ (33373)

11     exp nociceptors/ (8377)

12     (pain$ or agony or agoniz$ or nocicept$).mp. [mp=title, original title, abstract, name of substance

word, subject heading word] (334241)

13     9 or 10 or 11 or 12 (392032)

14     9 or 10 (230078)

15     4 and 14 (175)

16     5 and 14 (12)

17     exp War/ (25443)

18     exp Military Personnel/ (15657)

19     exp Military Medicine/ (21662)

20     exp Veterans/ (5122)

21     exp Veterans Disability Claims/ (209)

22     Hospitals, Veterans/ (4480)

23     exp "United States Department of Veterans Affairs"/ (3021)

24     (desert storm or gulf war or enduring freedom or iraqi freedom).mp. (1606)

25     exp Iraq War, 2003 ‐/ or exp Iraq/ (2569)

26     (iraq or soldier$ or veteran$ or combat$ or militar$ or battle$).mp. (77729)

27     17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 (94873)

28     exp "wounds and injuries"/ or in.fs. (580168)

29     27 and 28 (9834)

30     8 and 13 (1988)

31     limit 30 to humans (1836)

32     limit 31 to english language (1402)

33     limit 31 to abstracts (1447)

34     32 or 33 (1681)

35     4 and 13 (500)

36     limit 35 to humans (491)

37     limit 36 to english language (359)

38     limit 36 to abstracts (465)

39     37 or 38 (483)

40     13 and 29 (449)

VA-ESP September 2008 52
Pain in Patients with Polytrauma 

VA-ESP September 2008 53

41     limit 40 to humans (441)

42     limit 41 to english language (383)

43     limit 41 to abstracts (375)

44     42 or 43 (424)

45     34 or 39 or 44 (2480)

46     limit 45 to yr="2000 ‐ 2008" (1163)

47     limit 45 to yr="1902 ‐ 1999" (1317)

48     from 47 keep 1 (1)

Below is the search strategy designed by RC.  This search was saved in PubMed to provide automatic

weekly updates:

"Brain Injuries"(142)  

OR "Multiple Trauma"(142)  

OR "Blast Injuries"(142)  

OR TBI[All Fields]  

OR "traumatic brain injury"[All Fields]  

OR "traumatic brain injuries"[All Fields]  

OR polytrauma[All Fields]  

OR multitrauma[All Fields]  

OR "multi trauma"[All Fields]  

OR "poly trauma"[All Fields]  

OR (("Wounds and Injuries"(142) OR "injuries "[Subheading]) AND ("War"(142) OR "Iraq War, 2003 ‐"(142)

OR "Gulf War"(142)))  

AND ("pain"[MeSH Terms] OR pain[Text Word])
Pain in Patients with Polytrauma 

APPENDIX B. ARTICLE SCREENING FORM 

Author, Year______________________ Title ________________________________________ 

Key words or categories: 1. Does the study population constitute or include: 

a. Polytrauma patients in or after rehab phase ......................

b. Patients with blast-related headaches ............................

c. Neither a) nor b) ...............................................STOP 

2. Does the study intervention strictly address: 

a. Perioperative or surgical pain management ................STOP 

b. Treatment for burn injuries only ............................STOP 

3. Do the study outcomes include measures of pain (pain intensity 

 and/or pain-related function)? 

c. No ...............................................................STOP 

 d. Yes .................................................................... Notes: 

4. Is the text of the article in English? 

a. No ...............................................................STOP 

b. Yes ...................................................................

5. Does the article provide primary data? 

a. No (letter/commentary/non-systematic review) ............STOP 

b. Yes ...................................................................

6. If this article meets no other criterion, should it be saved 

for background? 

a. No ................................................................STOP 

b. Yes ...................................................................

Circle the Key Question(s) to which this article applies: 

6. Have reliable and valid measures and assessment tools been developed to measure pain intensity and 

pain-related functional interference among patients with cognitive deficits due to TBI? Which measures 

and tools are likely to be most useful in assessing pain in polytrauma patients with cognitive deficits due 

to TBI? 

7. Which treatment approaches are most likely to be effective in improving pain outcomes (pain intensity 

and functional interference) in polytrauma patients? Which pain treatment approaches are most likely to 

enhance overall rehabilitation efforts? 

8. Does blast-related headache pain differ in terms of phenomenology and treatment from other types of 

headache pain? Which treatments are best for persistent blast-related headache pain? 

9. What factors are associated with better and worse clinical outcomes among polytrauma patients? Have 

interventions been developed to specifically address these factors? 

10.What are unique provider and system barriers to detecting and treating pain among polytrauma patients? 

Have interventions been developed to effectively address these barriers? 

For reference: Definition of Polytrauma: Concurrent injury to two or more body parts or systems that results in cognitive, 

physical, psychological or other psychosocial impairments. Combat-related mental conditions co-occurring with injury to at 

least one other system also constitutes polytrauma. Scope of Review: The scope includes the assessment and treatment in 

rehabilitation and post-rehabilitation care settings of persistent pain or exacerbations of pain resulting from polytraumatic 

injuries. The scope of this review excludes the following: battlefield/emergency assessment and care; treatment of burn 

injuries; choice of surgical strategy, and perioperative management of injuries suffered in trauma. The scope also excludes 

post-traumatic/post-concussive headache unrelated to blast injury, unless the sample includes patients with moderate or greater

cognitive deficit. 

VA-ESP September 2008 54
Pain in Patients with Polytrauma 

VA-ESP September 2008 55

APPENDIX C. USPSTF QUALITY RATING CRITERIA

Randomized Controlled Trials (RCTs) and Cohort Studies 

Criteria

• Initial assembly of comparable groups: RCTs—adequate randomization, including concealment 

and whether potential confounders were distributed equally among groups; cohort studies—

consideration of potential confounders with either restriction or measurement for adjustment in the 

analysis; consideration of inception cohorts 

• Maintenance of comparable groups (includes attrition, cross-overs, adherence, contamination) 

• Important differential loss to follow-up or overall high loss to follow-up 

• Measurements: equal, reliable, and valid (includes masking of outcome assessment) 

• Clear definition of interventions 

• Important outcomes considered 

• Analysis: adjustment for potential confounders for cohort studies, or intention-to-treat analysis for 

RCTs (i.e. analysis in which all participants in a trial are analyzed according to the intervention to 

which they were allocated, regardless of whether or not they completed the intervention) 

Definition of ratings based on above criteria

Good: Meets all criteria: Comparable groups are assembled initially and maintained throughout the study 

(follow-up at least 80 percent); reliable and valid measurement instruments are used and applied 

equally to the groups; interventions are spelled out clearly; important outcomes are considered; 

and appropriate attention to confounders in analysis. 

Fair: Studies will be graded “fair” if any or all of the following problems occur, without the important 

limitations noted in the “poor” category below: Generally comparable groups are assembled 

initially but some question remains whether some (although not major) differences occurred in 

follow-up; measurement instruments are acceptable (although not the best) and generally applied 

equally; some but not all important outcomes are considered; and some but not all potential 

confounders are accounted for. 

Poor: Studies will be graded “poor” if any of the following major limitations exists: Groups assembled 

initially are not close to being comparable or maintained throughout the study; unreliable or 

invalid measurement instruments are used or not applied at all equally among groups (including 

not masking outcome assessment); and key confounders are given little or no attention.