No. 25 September 2008

Syntheses of the Evidence on Two Aspects 

of Pain Finds Little to Guide Clinicians 

The HSR&D Evidence-Based Synthesis Program (ESP) was established to provide 

timely and accurate syntheses of targeted health care topics of particular 

importance to VA managers and policymakers – and to disseminate these reports 

throughout VA. Recently, investigators at the Portland VA Medical Center 

conducted two systematic and comprehensive literature reviews focusing on pain. 

Pain in Patients with Polytrauma

In a review of the literature (published 1950 – July 2008), and a survey of active 

research, investigators sought to: address the assessment and management of 

pain in patients with polytraumatic injuries, identify factors associated with 

outcomes in these patients, and describe current or planned research that will 

address these issues. Overall, they found that the literature provides very limited 

evidence to guide clinicians in treating patients with polytrauma and pain, and 

that research specific to polytrauma and pain is needed. For example – 

z There were no published studies that assessed measures of pain intensity 

or pain-related functional interference among patients with cognitive 

deficits due to traumatic brain injury (TBI). 

z There were no studies that tested the efficacy or effectiveness of specific 

pain treatment approaches among patients with polytrauma. 

z Contrary to what is often reported in the literature, there was limited 

evidence to support the contention that patients with mild TBI are more 

likely to have headache or other pain than patients without TBI. 

z Factors found to be associated with worse pain-related outcomes in 

patients with polytrauma were: multiplicity of injury, head injury or 

cognitive disability, and lower limb injuries. Limited evidence showed that 

factors associated with better outcomes were: younger age, higher 

education, and having a white collar job. 

z There was almost no evidence that addresses provider and system barriers 

to the treatment of pain among patients with polytrauma. 

The authors note numerous areas that require further research, such as the study 

of associations between comorbid psychiatric conditions and pain, as well as 

comparisons of veterans with headache presumed to be blast-related to veterans 

with headache not known to be blast-related. 

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HSR&D findings and 
Pain in Acute Care Setting

In this literature review (1950 – July 2007), investigators focused on the delivery 

of effective pain care in the acute care setting and, again, found a paucity of 

evidence. Overall, they found that current practice in managing inpatients with 

acute medical pain is based largely on experience in post-surgical patients and on 

expert opinion. Other findings include: 

z Compared with post-surgical pain, cancer pain, and chronic pain, evidence 

about acute pain in medical conditions requiring hospitalization is sparse. 

z There are no good quality studies that compare the different pain 

assessment methods in the general medical inpatient setting. 

z Almost no evidence exists to guide the management of pain in delirium. 

z Evidence about treating pain in medical inpatients with substance use 

disorders or chronic opioid use is weak. 

The lack of evidence suggests that the VA should characterize current practice, 

avoid overuse of patient controlled analgesia or other related technologies until 

there is stronger evidence about safety in VA medical ward settings, and 

emphasize a robust research agenda. Several research recommendations are 

included in the report, such as research that would evaluate different initial 

treatment intensities including the clinical effectiveness and safety of patientcontrolled analgesia. 

information to policy 

makers, managers, 

clinicians, and 

researchers working to 

improve the health and 

care of veterans. 

To view the full reports, go to http://www.hsrd.research.va.gov/publications/esp/.