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Dobscha SK, Campbell R, Morasco BJ, et al. Pain in Patients with Polytrauma: A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2008 Sep.

SUMMARY AND DISCUSSION

Pain from polytraumatic injuries poses numerous challenges during and after rehabilitation treatment. Pain assessment and intervention efforts are further complicated when the injuries include TBI. The overall purpose of this project was to identify and synthesize evidence on the assessment and treatment of pain in polytrauma patients.

Overall, the literature provides very limited evidence to guide clinicians in this area. Although some previous investigations indicate that pain may interfere with neurocognitive performance in TBI patients, there have been no published studies examining approaches to assessing pain among patients with moderate to severe TBI. Studies that have been done with patients with cognitive impairment due to dementia indicate that most cognitively impaired individuals can understand at least one self-assessment measure. Guidelines suggest that for patients with dementia who cannot understand any of several self-assessment measures available, an observational assessment measure or input from family, friends, or staff who know patients well, or empiric pain treatment if the patient has diagnoses usually associated with pain, may be helpful. How well these findings and guidelines might apply to younger patients with cognitive impairment due to TBI is currently unknown. One ongoing VA research study is examining the validity and reliability of 4 pain intensity scales in persons with polytrauma and cognitive impairment, and an additional VA study is examining the utility of a CPRS pain assessment template module to assist clinicians in evaluating pain in patients with cognitive impairment in PRCs.

The literature also provides very limited evidence to guide clinicians in selecting among non-surgical pain treatments in patients with polytrauma. Aside from one good quality retrospective cohort study indicating that rehabilitation may improve outcomes among patients with trauma related amputation, no systematic pain intervention studies have been done in the polytrauma population. A number of case reports suggest possible approaches to treating pain in polytrauma patients, ranging from intrathecal baclofen pumps for pain associated with spasticity to alternative therapies including healing touch. These potential treatment modalities have not been rigorously tested with polytrauma patients. Despite potential concerns about adverse effects, we found only a single case report regarding the use of opioids for pain other than for acute care among TBI patients. Several ongoing research projects are testing interventions in patients with polytrauma. These interventions include stepped care for chronic musculoskeletal pain, advanced regional anesthetic techniques, brief cognitive headache management therapy for persistent blast-related headache, and Virtual Reality Exposure Therapy and Imaging for veterans with PTSD and TBI.

Although several studies show that headache (as well as auditory deficits and otalgia) is common among blast injury patients, there are no published studies describing how blast-related headache might differ in terms of phenomenology or treatment from other types of headache pain. One VA study is currently examining clinical characteristics of headache conditions among OEF/OIF veterans referred to a VA Blast Injury Clinic.

From a number of cohort studies, there is moderate evidence showing that injury factors (including location, severity, and the number of different injuries) are associated with pain and functional status over time. TBI itself is associated with worse outcomes when compared to polytrauma patients without TBI, and there is some evidence that pain is common among TBI patients, present in one-third to one-half of patients up to five years post-injury. However, contrary to what is often reported in the literature and reported in a recent systematic review, we found very limited evidence to support that patients with mild TBI are more likely to have headache or other pain than patients without TBI. While predominantly cross-sectional studies suggest that patients with mild TBI may be more likely to have headache pain than patients with moderate or severe TBI, six prospective cohort studies and several additional cross-sectional studies did not find a relationship between TBI severity and headache prevalence. Most of the cross-sectional studies were done in outpatient settings up to several years post-injury, and did not adjust for potential confounders that may influence relationships between TBI severity and pain. In these studies, cases were identified based on who was referred or attended outpatient follow-up visits. It is thus likely that differences in sample composition contribute to the differences in findings between the cross-sectional and cohort studies, in that patients with mild TBI may be more likely to be referred to or attend outpatient follow-up appointments when they have bothersome or persistent symptoms such as headache.

Overall, we found limited evidence regarding other patient characteristics that are associated with pain-related outcomes in polytrauma patients. Factors found to be associated with worse outcomes across at least several studies were: multiplicity of injury, head injury or cognitive disability, and lower limb injuries. Factors associated with better outcomes in a few studies were: younger age, higher educational achievement, and having a white collar job. Among TBI patients, factors found to be associated with pain and pain-related function in several studies included depression, PTSD, insomnia, and fatigue. Fifteen ongoing research studies will provide additional information about patient factors associated with outcomes in polytrauma patients. Seven studies utilizing cohort designs will follow samples of OEF/OIF soldiers or OEF/OIF veterans over time, and should help to identify important correlates of pain-related outcomes among polytrauma patients.

Finally, there is almost no evidence that addresses provider and system barriers to treatment of pain among polytrauma patients. In one rigorously conducted qualitative study, providers reported that polytrauma patients are very complex to treat, and that the work with this population is very challenging and emotionally taxing. In order to provide high quality care to this complex patient population, clinicians have increased their use of multidisciplinary and concurrent care, and consultation from experts. One active study, which is using qualitative and quantitative methods to evaluate the utility of CPRS pain assessment tools, is likely to generate information regarding provider or system barriers to treating pain among polytrauma patients.

Cover of Pain in Patients with Polytrauma
Pain in Patients with Polytrauma: A Systematic Review [Internet].
Dobscha SK, Campbell R, Morasco BJ, et al.
Washington (DC): Department of Veterans Affairs (US); 2008 Sep.

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