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Screening for Acute Factors That Predict Pain Post Trauma: A Pilot Study Allyson Browne, Kim Fong, Sudhakar Rao, Fiona Wood, Stephan Schug Royal Perth.

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Presentation on theme: "Screening for Acute Factors That Predict Pain Post Trauma: A Pilot Study Allyson Browne, Kim Fong, Sudhakar Rao, Fiona Wood, Stephan Schug Royal Perth."— Presentation transcript:

1 Screening for Acute Factors That Predict Pain Post Trauma: A Pilot Study Allyson Browne, Kim Fong, Sudhakar Rao, Fiona Wood, Stephan Schug Royal Perth Hospital University of Western Australia

2 Aims   Test a model of screening for pain and psychological risk factors in a trauma setting   Identify risk factors for pain and psychological outcomes following trauma

3 Pain After Traumatic Injury   Traumatic injury has been proposed as either a causal factor or trigger of chronic pain. Buskila & Neumann (2000); Staud (2004)   More than 40% of patients with limb threatening lower extremity trauma reported clinically significant pain intensity at 7 years post trauma. Castillo et al (2006)

4 What Predicts Persistent Pain Following Trauma?   High levels of acute & post surgical pain have been linked to increased risk of persistent pain. Gehling, et al (1999); Perkins & Kehlet (2000)   Growing consensus that chronic pain may be the result of Central Neuroplasticity. Siddall & Cousins (2004) Woolf (1995)   Converging evidence suggesting that the onset of persistent pain post trauma is independent to injury characteristics and surgical decisions Jenewein et al (2009) Castillo et al (2006) Ashburn & Fine (1989)

5 Predicting Pain Post Trauma Study Group & Trauma Populations Follow-Up Number (% attrition) Time Frame Acute PredictorsOutcomesOutcome Measures Williamson et al (2009) Orthopaedic 1290 (45%)* *% of available sample 6 MoLow education Comp status Pain severity Pain disability Hx Pain Intensity Pain Disability Anxiety Depression VAS 11 point SF12 (QoL) Castillo et al (2006) Lower Limb 397 (28%)7 yearsLow education Low self efficacy Alcohol Hx Pain at 3/12 Insomnia 3/12 Depress / Anx 3/12 Pain Intensity Pain Interference Graded Chronic Pain Questionnaire Corry et al (2009) Edwards et al (2007) Burns 171 (48%) 249 (53%) 2 Years PTSD but not Pain Depression but not Anxiety Physical Fn Physical Role Pain Physical Fn SF 36 Jenewein et al (2009) Holmes et al (2010) Heterogenous 90 (26%) 242 (17%) 3 Years 3 Mo PTSD Length of Stay Somatization Age, Gender Alcohol Hx Physical Fn Hx Pain severity Morphine Presence of Pain Disability Health Care Use Med Use Pain Intensity Clinical Interview VAS 11 point

6 Trauma Pain as Distinct to CLBP   Pain experience associated with recent life or serious injury threat.   People who attribute pain symptoms to injury are more likely to view any sensation as harmful, thereby increasing anxiety and avoidance behaviour. Turk et al (1996) PTSD symptoms have been shown to predict pain symptom severity post trauma. Sterling et al (2005) Jenewein et al (2009)

7 Linking Pain and PTSD Post Trauma   PTSD and depression occur 10 and 3 times more often respectively within 12 months of injury among Australian trauma survivors compared with community samples. O’Donnell et al (2004)   Centrality of threat-expectancy, hypervigilance, and fear avoidance is common to both pain and traumatic stress evolution. Sharp & Harvey (2001)   Stress response system dysregulation is common feature to both PTSD and fibromyalgia developing after MVA. McLean et al (2005) Trauma patients with PTSD at 3 months post injury received less morphine than those who did not develop PTSD. Bryant et al (2009)

8 Baseline Predictors (< 1 mo) Demographic Age Gender Education Compensation Status Employment Status Rural vs Metro Injury & Surgery Related ISS Mechanism of Injury Number Surgeries Amputation/Prosthesis Type of Injury Pain Severity & Quality Analgesia Psychological Acute PTSD symptoms Posttraumatic Adjustment Depression Self-Efficacy for Coping with Pain Alcohol Consumption Mental Health History Outcomes (6 Mo) Functional Return to Work Compensation Status Activities of Daily Living Financial Impact Health Care Use Physical Mobility Balance Pain Severity & Quality Pain Related Disability Psychological PTSD Sx & Diag Depression Sx & Diag Alcohol Consumption Patient Satisfaction Measures (6 Mo) Functional Clinical Interview Functional Independence Measure (ADLs) Physical 6 Minute Walk Test Berg Balance Scale Pain Detect Brief Pain Inventory Clinical Interview Psychological Posttraumatic Checklist Civilians Centre Epidemiological Studies Depression Scale AUDIT Patient Satisfaction Quest MINI Diagnostic Interview

9 Methods   All new trauma admissions identified with LOS > 24 hrs.   Excluded: Moderate/Severe Head Injury PTA > 24 hrs or GCS < 13 at admission Severe ETOH Dependence High Suicidal Risk Overseas or Interstate Visitor Non-English Speaking   Risk Screening within 1 Month Post Injury: Medical file review Semi-Structured Clinical Interviews Standardised self report measures

10 Excluded (n=27) Did not consent (n = 27) Consented and screened (n=149) Excluded(n=7) Screening not completed (n=3) Not ‘at risk’ (n = 2) Moderate head injury (n=1) Age < 18 years (n=1) Randomised (n=142) Allocated to MCC (n=69)Allocated to UC (n=73) Excluded (n =15) Discharged from hospital (n=8) Moderate head injury (n=3) Currently actively suicidal (n = 2) Intoxicated/Withdrawal (n=1) Age < 18 years (n=1) Approached for consent (n=176) Assessed for eligibility (n = 191) Analysed 6 Month outcomes (n=67) Lost to follow up (n =75) Working(n=6) Remote location(n=6) Unable to contact (n=50) Discontinued (n=1) Withdrawn(n=2) Incomplete data (n=10) Recruitment Flow Chart Attrition 53% at 6 Months

11 Screening Feasibility & Follow-Up   Approximately 11% of eligible admissions were screened within the recruitment phase.   Staffing limited to 1 part-time research assistant.   High attrition at 6 months associated with high alcohol consumption at baseline, male, younger age.

12 Sample Characteristics   Mean Age = 36 years (SD = 15.57)   Mean ISS = 9.65 (SD = 3.82)   Mdn LOS = 13 days (SD = 11.93)   74% male   20% prior psych diagnosis   15% positive suicide risk   81% employed Mechanism of Injury

13 Clinical Characteristics Type of Injury 72% (n = 92) Surgery 92 % (n = 87) GA 4% (n = 5) Amputation 11.7% Wound Infection 30% ETOH related injury

14 Baseline Pain & Psychological Factors %

15 Baseline & 6 Month Findings 6 Month Clinical Findings 42% diagnosed with pain related disability by Pain Specialist. 10% & 15% diagnosed with Depression & PTSD respectively. 15% diagnosed with comorbid Depression & PTSD.

16 Predicting PTSD at 6 Months Final Step and Acute Predictorsβt∆R 2 ∆F 2.Age Gender Gender Injury Severity Injury Severity Trial Group Trial Group Acute Traumatic Stress Acute Traumatic Stress Acute Depression Acute Depression Posttraumatic Adjustment Alcohol Use Average Pain Severity Neuropathic symptoms.10.10-.02-.02.13.04.51.38 -.40.221.281.31-.20-.271.27.38 5.08*** 4.82*** -5.05*** 2.54*.70.22.85*** *p <.05, ***p <.001 Acute psychological, pain, and alcohol use predicted 70% of the variance in PTSD symptom severity at 6 months after controlling for age, gender, and injury severity.

17 Predicting Pain at 6 Months Final Step and Predictorsβt∆R 2 ∆F 2.Age Gender Gender Injury Severity Injury Severity Trial Group Trial Group Acute Traumatic Stress Acute Traumatic Stress Acute Depression Acute Depression Posttraumatic Adjustment Alcohol Use Alcohol Use Average Pain Severity Average Pain Severity Neuropathic symptoms-.03-.17-.08-.09.03-.23.33.15.07 -.22-1.38-.61-.70.21-1.32 2.02*1.16.55 2.44*.273.24* *p <.05 Acute psychological, pain, and alcohol use predicted 27% of the variance in pain severity at 6 months after controlling for age, gender, and injury severity.

18 Predicting Physical Function at 6 Months Final Step and Acute Predictorsβt∆R 2 ∆F 2.Age Gender Gender Injury Severity Trial Group Trial Group Acute Traumatic Stress Acute Traumatic Stress Acute Depression Acute Depression Posttraumatic Adjustment Average Pain Severity Alcohol Use Alcohol Use-.14.03 -.34.09.16-.36 -.49.44.10-1.12.21 -2.81*.80.99-2.12 -3.10** 3.47**.79.456.75*** Acute psychological, pain, and alcohol use predicted 45% of the variance in mobility at 6 months after controlling for age, gender, and injury severity. *p <.05, **p<.01, ***p <.001

19 Key Findings   A small proportion of eligible patients were screened by research staff   The prevalence of clinically significant pain and psychopathology was high at both baseline and 6 months   Standardised measures of acute pain, alcohol, and posttraumatic responses predicted variance in subsequent pain, psychological, and physical outcomes

20 Implications   Trauma Committee of RACS refers to 2007 ANZCA ‘Guidelines on Acute Pain Management’   ANZCA Guidelines: Regular assessment of pain during rest and activity using patient self report, regular evaluation of effectiveness of acute pain management.   Translation of the guidelines & application of research evidence in acute trauma settings?

21 Future Directions   Larger scale prospective multi-site studies required   Standardized multidisciplinary measures of both predictors and outcomes required   Further feasibility studies required to examine implementation of pain and post trauma hospital wide screening tools   A new trauma-specific model of persistent pain evolution?

22 Dr Allyson Browne allyson.browne@uwa.edu.au University of Western Australia


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