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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.


Polytrauma is defined in the VHA Polytrauma Rehabilitation Centers Directive dated June 8, 2005 as: “injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability.” The definition of polytrauma has since expanded to include concurrent injury to two or more body parts or systems that results in cognitive, physical, psychological or other psychosocial impairments. Traumatic Brain Injury (TBI) often occurs in polytrauma and in combination with other disabling conditions including amputation, auditory or visual impairments, spinal cord injury (SCI), post-traumatic stress disorder (PTSD), and other mental health conditions.

Pain resulting from polytraumatic injuries poses numerous challenges during rehabilitation treatment and afterwards. Treatments typically used to reduce pain in these individuals (for example, oral opioids) have the potential to interfere with the active rehabilitation needed to restore function.

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.


Major advances in body armor technology and battlefield medicine have improved survival from combat injuries that would have been fatal in previous wars.(1) Data from the Department of Defense indicate that the lethality of war wounds has decreased from 24% in the Vietnam and Persian Gulf Wars to 10% in the current Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts.(2) Survivors of polytraumatic injuries among soldiers returning from the current conflicts tend to have more complex injuries and emotional trauma than typically seen in the past wars.(3, 4)

Among 119 casualties admitted to Walter Reed Army Medical Center from OIF during March 1 to July 1, 2003, 39% had sustained gunshot wounds, 31% sustained blast and shrapnel injuries, and 34% had blunt/motor vehicle collision mechanisms.(5) Among these 119 patients there were 184 injured areas, and the location of injury was the lower extremity for 62% of patients, the upper extremity for 30%, the head and neck for 25%, the chest for 25%, and the abdomen for 16%. Among 52 patients with orthopedic injuries evacuated during OEF between December 2001 and January 2003, 15 (29%) had suffered traumatic amputations, of which 5 (33.3%) were below-knee.(6) All amputations were caused by land mines or exploded ordinance.

Twenty-eight percent of all individuals medically evacuated to the Walter Reed Army Medical Center (WRAMC) due to combat injuries during OEF/OIF had a TBI, according to a report in 2006.(4) By contrast, 12 to 14% of all combat casualties in the Vietnam War had a brain injury.(7) In the current conflicts, Kevlar body armor and helmets have improved overall survival rates and reduced the frequency of penetrating head injuries.(7) Because mortality from substantial brain injuries among U.S. combatants in Vietnam was 75% or greater, soldiers with recognized brain injuries made up only a small fraction of the casualties. Between January 2003 and February 2005, 59% of all patients who were exposed to a blast and admitted to WRAMC were given a diagnosis of TBI.(7) Closed TBI accounted for 88% of all TBI. Moderate to severe TBI accounted for 56% of TBI cases. Nineteen percent of TBI patients sustained concomitant amputation.

Brain injuries from blasts may go undiagnosed and untreated in patients with polytrauma because of the attention focused on more visible injuries. Commonly overlooked pain-related conditions in patients with polytrauma may include soft-tissue damage, PTSD, nerve damage, hearing loss and tinnitus, chronic infections, vision changes, lung injury, vestibular problems, and undiscovered shrapnel fragments.(8) In addition to the direct effects of blasts, injuries can result from the structural collapse and fragmentation of buildings and vehicles, and may include crush injuries and compartment syndrome.(9)

Under a new system established by the VHA in 2005, severely injured soldiers with TBI are being referred early in their treatment to one of four VA medical centers in Richmond, VA; Tampa, FL; Palo Alto, CA; and Minneapolis, MN) designated as Polytrauma Rehabilitation Centers (PRCs). The four PRCs approach treatment of polytrauma patients using a mechanism-of-injury approach to provide a comprehensive, efficient, and interdisciplinary system of care.(8) Each of the four PRCs has been identifying six to 10 cases of TBI per month that were missed in military hospitals.(10)

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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