Pain in Patients with Polytrauma

EXECUTIVE SUMMARY

BACKGROUND 

Pain resulting from polytraumatic injuries poses numerous challenges during and after 

rehabilitation treatment. The objectives of this report are to systematically review the 

literature to address the assessment and management of pain in patients with 

polytraumatic injuries, to identify patient, clinician and systems factors associated with 

pain-related outcomes in these patients, and to describe current or planned research 

addressing the key questions in this report. 

The key questions were: 

1. 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? 

2. A. Which treatment approaches are most likely to be effective in improving pain 

outcomes (pain intensity and functional interference) in polytrauma patients? 

B. Which pain treatment approaches are most likely to enhance overall 

rehabilitation efforts? 

3. A. Does blast-related headache pain differ in terms of phenomenology and 

treatment from other types of headache pain? 

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

4. What patient factors are associated with better and worse pain-related clinical 

outcomes among polytrauma patients? Have interventions been developed to 

specifically address these factors? 

5. What are unique provider and system barriers to detecting and treating pain among 

polytrauma patients? Have interventions been developed to effectively address 

these barriers? 

We also sought to identify and describe current or planned research that is addressing or 

will address the key questions. 

METHODS 

Literature Search

Two research librarians independently designed search strategies based on the key 

questions, and conducted searches in Medline of literature published from 1950 through 

July 2008. The results of both searches were combined into a single reference library. 

Three researchers trained in the critical analysis of literature assessed for relevance the 

abstracts of citations identified from these literatures searches. Full-text articles of 

potentially relevant abstracts were retrieved for further review. Reference lists from 

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Pain in Patients with Polytrauma

articles were reviewed to find additional articles for inclusion. We also searched for inprogress and unpublished trials. Due to a limited number of studies using controls or 

comparators, we included cross-sectional and case report/case series studies in the review 

for some key questions, We systematically rated the quality of cohort and case-control 

design studies. 

Active Research

The PI sent email communications inquiring about active or planned research to a number 

of groups and individuals identified through VA workgroups, personal knowledge of 

investigators, recent publications, and several web-databases which included information 

about funded VA and non-VA projects. Email communications described the evidence 

review project, and asked respondents to describe any relevant projects they were involved 

in or planning as well as to identify other investigators who might be working in these 

areas (snowball approach). Initial email messages were sent at the end of January 2008; 

email messages to newly identified investigators and follow-up communications occurred 

continuously until August 28, 2008. 

RESULTS 

We screened 3252 titles and performed a more detailed review of 578 articles. From these, 

we identified one systematic review, one qualitative research study, and 93 observational 

studies that addressed at least one of the key questions. Studies were excluded for the 

following reasons: 1) the study population did not constitute or include polytrauma 

patients or patients with blast-related headaches; 2) the study addressed perioperative or 

surgical pain management or management of specific orthopedic injuries or only short term 

(less than 3 months post-injury) outcomes; 3) the study outcomes did not include measures 

of pain intensity or pain-related function; 4) the text of the article was non-English. The 

primary findings for each key question are summarized below. Secondary findings are 

presented in further detail within the report. 

KEY QUESTION #1 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? 

There were no published studies that assessed measures of pain intensity or painrelated functional interference among patients with cognitive deficits due to TBI.

KEY QUESTION #2 A. Which treatment approaches are most likely to be effective in 

improving pain outcomes (pain intensity and functional interference) in polytrauma 

patients? B. Which pain treatment approaches are most likely to enhance overall 

rehabilitation efforts? 

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Pain in Patients with Polytrauma

2A: There were no randomized controlled trials, systematic reviews, prospective 

cohort, case-control, or systematic observational studies that tested the efficacy or 

effectiveness of specific pain treatment approaches among patients with polytrauma. 

2B: One fair-quality retrospective cohort study of patients with trauma-related 

amputation demonstrated that after controlling for demographic factors, injury 

characteristics and other medical morbidity, inpatient rehabilitation was marginally 

associated with increased likelihood of return to work and decreased likelihood of 

reduced hours of work.(GRADE: Very Low) 

KEY QUESTION #3 A. Does blast-related headache pain differ in terms of 

phenomenology and treatment from other types of headache pain? B. Which treatments 

are best for persistent blast-related headache pain? 

There were no randomized controlled trials, cohort studies, case-control studies, or 

other systematic observational studies that compared patients with blast-related 

headache to patients with other types of headache or that specifically addressed 

treatments for blast-related related headache pain. 

KEY QUESTION #4 What patient factors are associated with better and worse clinical 

outcomes among polytrauma patients? Have interventions been developed to specifically 

address these factors? 

There were no randomized controlled trials. One systematic review, 9 cohort, 3 casecontrol, and 13 cross-sectional studies specifically addressed patient factors associated 

with outcomes in TBI patients. Thirty-two cohort, 11 cross-sectional, and 4 case-control 

studies addressed patient factors associated with outcomes in patients with other types of 

polytraumatic injuries. 

Traumatic Brain Injury

One fair-quality systematic review involving 23 studies and 4,206 patients showed that 

overall, 58% of patients with TBI have chronic headache, and that brain injury is 

associated with headache even after adjustment for post-traumatic stress disorder 

(PTSD). This review also found that patients with mild TBI were more likely to have 

headache than patients with moderate or severe TBI. However, our review, which 

included studies not included in the above study, showed mixed findings regarding the 

association between severity of TBI and pain (GRADE: Very Low). 

Psychological factors, including depression and posttraumatic stress disorder (PTSD), 

and insomnia and fatigue are associated with pain in TBI patients. (GRADE: Low) 

Other injuries in polytrauma patients

Characteristics of injuries (location, severity, and whether they are multiple) are 

associated with clinical outcomes including persistent pain and functional status. 

Specific factors associated with worse pain-related outcomes include: multiple injuries, 

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Pain in Patients with Polytrauma

foot injuries or injuries below the knee joint, and concurrent head injury or cognitive 

disability. (GRADE: Low) 

Other factors associated with better outcomes in some studies of patients with 

polytraumatic injuries other than TBI were younger age, higher educational 

achievement, having a white collar job or higher income. (GRADE: Very Low) 

KEY QUESTION #5 What are unique provider and system barriers to detecting and 

treating pain among polytrauma patients? Have interventions been developed to 

effectively address these barriers? 

There were no randomized controlled trials, cohort studies, case-control studies, or 

other systematic observational studies that addressed provider and system barriers to 

detecting and treating pain among polytrauma patients. One qualitative study of 

providers from four VA Polytrauma Rehabilitation Centers (PRCs) addressed potential 

provider and system barriers to treating polytrauma patients. In interviews, providers 

reported that polytrauma patients are very complex to treat, and that the work with this 

population is very challenging and emotionally taxing. The investigators and study 

respondents suggested that increasing use of multidisciplinary and concurrent care and 

consultation from experts may be necessary to provide the care that is needed.

Results—Active Research 

Nineteen relevant active or planned projects were identified and project data were 

collected on 18 of these projects. Fifteen of the studies should generate information 

regarding patient factors that may contribute to pain-related outcomes among polytrauma 

patients (Key Question 4), and 4 studies are testing interventions for pain among 

polytrauma patients (Key Question 2). One active study will test the reliability and validity 

of measures to assess pain in cognitively-impaired TBI patients and another study is using 

primarily qualitative methods to examine the utility of a Computerized Patient Record 

System (CPRS) pain assessment template module to assist clinicians in evaluating pain in 

PRC patients with cognitive impairment (Key Question 1). One study is examining the 

phenomenology and treatment of blast vs. other types of headache (Key Question 3), and 

one study is addressing provider and systems barriers to detecting and treating pain in 

polytrauma patients (Key Question 5).

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