1. Pain problems, pain-related impairments, and emotional problems in polytrauma patients Robyn L. Walker, Ph.D. Clinical Psychologist James A. Haley Veterans’ Hospital Polytrauma Rehabilitation Program Chronic Pain Rehabilitation Program Robyn L. Walker, Ph.D. Clinical Psychologist James A. Haley Veterans’ Hospital Polytrauma Rehabilitation Program Chronic Pain Rehabilitation Program

2. Pain in OIF/OEF Returnees With higher survival rates and the large group of deployed soldiers, comes a greater number of injured who must learn to live with their new disabilities.With higher survival rates and the large group of deployed soldiers, comes a greater number of injured who must learn to live with their new disabilities. As expected, pain is highly prevalent among these soldiers injured in the OIF/OEF conflicts.As expected, pain is highly prevalent among these soldiers injured in the OIF/OEF conflicts. Given the severity and complexity of OIF/OEF combat wounds, the VA has four Polytrauma Rehabilitation Centers (PRCs) that are the primary VA receiving facilities for veterans and active duty military with polytrauma injuries.Given the severity and complexity of OIF/OEF combat wounds, the VA has four Polytrauma Rehabilitation Centers (PRCs) that are the primary VA receiving facilities for veterans and active duty military with polytrauma injuries. With higher survival rates and the large group of deployed soldiers, comes a greater number of injured who must learn to live with their new disabilities.With higher survival rates and the large group of deployed soldiers, comes a greater number of injured who must learn to live with their new disabilities. As expected, pain is highly prevalent among these soldiers injured in the OIF/OEF conflicts.As expected, pain is highly prevalent among these soldiers injured in the OIF/OEF conflicts. Given the severity and complexity of OIF/OEF combat wounds, the VA has four Polytrauma Rehabilitation Centers (PRCs) that are the primary VA receiving facilities for veterans and active duty military with polytrauma injuries.Given the severity and complexity of OIF/OEF combat wounds, the VA has four Polytrauma Rehabilitation Centers (PRCs) that are the primary VA receiving facilities for veterans and active duty military with polytrauma injuries.

3. Polytrauma Pain Tampa Polytrauma Rehabilitation Center (TPRC) is an inpatient rehabilitation program that has been treating combat related polytrauma patients since early 2003Tampa Polytrauma Rehabilitation Center (TPRC) is an inpatient rehabilitation program that has been treating combat related polytrauma patients since early 2003 The TPRC utilizes an interdisciplinary approach to assess and treat the entire range of impairments and needs of the combat wounded and their familiesThe TPRC utilizes an interdisciplinary approach to assess and treat the entire range of impairments and needs of the combat wounded and their families Pain assessment and management is recognized as an important component of rehabilitative carePain assessment and management is recognized as an important component of rehabilitative care Tampa Polytrauma Rehabilitation Center (TPRC) is an inpatient rehabilitation program that has been treating combat related polytrauma patients since early 2003Tampa Polytrauma Rehabilitation Center (TPRC) is an inpatient rehabilitation program that has been treating combat related polytrauma patients since early 2003 The TPRC utilizes an interdisciplinary approach to assess and treat the entire range of impairments and needs of the combat wounded and their familiesThe TPRC utilizes an interdisciplinary approach to assess and treat the entire range of impairments and needs of the combat wounded and their families Pain assessment and management is recognized as an important component of rehabilitative carePain assessment and management is recognized as an important component of rehabilitative care

4. Polytrauma Patient Description n = 50 12.6 (SD = 1.1) Mean Age in Years 28.9 (SD = 8.7) Mean Years of Education Gender Military Service Branch Male 98% Army Army 40% Female 2% Marines Marines 34% Navy Navy 18% Ethnicity National Guard National Guard 8% Caucasian 82% African-American 8% Deployment Theater Hispanic 8% Iraq Iraq 98% American I Indian 2% Afghanistan Afghanistan 6% Other Territories Other Territories 2% Marital Status Married Married 56% Never Married Never Married 40% Divorced Divorced 4%

5. Polytraumatic Injuries Method of Injury:Method of Injury: –IEDs: 70% –Airborne shrapnel: 26% –Mortar rounds: 22% –Gunshot wounds: 6% Type of Injury (Average #: 3.3):Type of Injury (Average #: 3.3): –TBI: 80% Closed: 22%Closed: 22% Penetrating: 58%Penetrating: 58% –Ortho: 50% –Soft Tissue: 48% –Hearing: 48% Method of Injury:Method of Injury: –IEDs: 70% –Airborne shrapnel: 26% –Mortar rounds: 22% –Gunshot wounds: 6% Type of Injury (Average #: 3.3):Type of Injury (Average #: 3.3): –TBI: 80% Closed: 22%Closed: 22% Penetrating: 58%Penetrating: 58% –Ortho: 50% –Soft Tissue: 48% –Hearing: 48% –Eye: 44% –Burns: 12% –Compartment syndrome: 12% –Limb amputation: 12% –SCI: 10%

6. Cognitive Functioning Cognitive limitations are quite common among the TPRC soldiersCognitive limitations are quite common among the TPRC soldiers Average Admission Rancho Los Amigos Scale Score was 5.2 (SD = 1.9)Average Admission Rancho Los Amigos Scale Score was 5.2 (SD = 1.9) 71% had Rancho scores below 7 at admission indicating moderate to severe TBI71% had Rancho scores below 7 at admission indicating moderate to severe TBI Cognitive limitations are quite common among the TPRC soldiersCognitive limitations are quite common among the TPRC soldiers Average Admission Rancho Los Amigos Scale Score was 5.2 (SD = 1.9)Average Admission Rancho Los Amigos Scale Score was 5.2 (SD = 1.9) 71% had Rancho scores below 7 at admission indicating moderate to severe TBI71% had Rancho scores below 7 at admission indicating moderate to severe TBI

7. Polytrauma Pain Of the 50 records reviewed, 96% experienced > 1 pain problem during rehabilitationOf the 50 records reviewed, 96% experienced > 1 pain problem during rehabilitation Valid pain intensity ratings were obtained from 68% of those soldiers at admissionValid pain intensity ratings were obtained from 68% of those soldiers at admission –Mean: 5.6 (SD: 2.2) Of the 50 records reviewed, 96% experienced > 1 pain problem during rehabilitationOf the 50 records reviewed, 96% experienced > 1 pain problem during rehabilitation Valid pain intensity ratings were obtained from 68% of those soldiers at admissionValid pain intensity ratings were obtained from 68% of those soldiers at admission –Mean: 5.6 (SD: 2.2)

8. Polytrauma Pain Average duration of pain at admission was 83.7 days (SD: 152.7; Range: 24 - 1054)Average duration of pain at admission was 83.7 days (SD: 152.7; Range: 24 - 1054) 70% of soldiers with pain, experienced it in more than one site70% of soldiers with pain, experienced it in more than one site –Mean: 2.3 (SD: 1.4) Average duration of pain at admission was 83.7 days (SD: 152.7; Range: 24 - 1054)Average duration of pain at admission was 83.7 days (SD: 152.7; Range: 24 - 1054) 70% of soldiers with pain, experienced it in more than one site70% of soldiers with pain, experienced it in more than one site –Mean: 2.3 (SD: 1.4)

9. Polytrauma Pain Locations Primary Pain Location –Head = 32% –Leg(s) = 23% –Shoulder(s) = 13% –Arm(s) = 11% –Hand(s) = 6% –Neck = 4% Primary Pain Location –Head = 32% –Leg(s) = 23% –Shoulder(s) = 13% –Arm(s) = 11% –Hand(s) = 6% –Neck = 4% Secondary Pain Location –Head = 22% –Low back = 16% –Face = 14% –Hand(s) = 14% –Leg(s) = 12% –Neck = 10% –Abdomen = 10%

10. Pain Related Impairments Recreational or physical activity: 42%Recreational or physical activity: 42% Emotional functioning: 34%Emotional functioning: 34% Social activity: 18%Social activity: 18% Family relationships: 18%Family relationships: 18% Sleep: 14%Sleep: 14% Sexual functioning: 2%Sexual functioning: 2% Recreational or physical activity: 42%Recreational or physical activity: 42% Emotional functioning: 34%Emotional functioning: 34% Social activity: 18%Social activity: 18% Family relationships: 18%Family relationships: 18% Sleep: 14%Sleep: 14% Sexual functioning: 2%Sexual functioning: 2%

11. Mental Health Issues 78% received a Mental Health consult78% received a Mental Health consult Mental Health DiagnosesMental Health Diagnoses –PTSD: 56% –Adjustment Disorder: 46% –Depressive Disorder: 28% –Acute Stress Disorder: 5% –Substance Abuse: 5% –MDD: 3% 78% received a Mental Health consult78% received a Mental Health consult Mental Health DiagnosesMental Health Diagnoses –PTSD: 56% –Adjustment Disorder: 46% –Depressive Disorder: 28% –Acute Stress Disorder: 5% –Substance Abuse: 5% –MDD: 3% Mental Health TreatmentMental Health Treatment –Medication: 100% –Group: 59% –Individual: 49% –Family: 13%

12. Polytrauma Pain Management Medication management: 100%Medication management: 100% Physical therapy: 40%Physical therapy: 40% –TENS unit: 6% Occupational therapy: 38%Occupational therapy: 38% Cognitive behavioral therapy: 25%Cognitive behavioral therapy: 25% Nerve blocks: 8%Nerve blocks: 8% Medication pump implantation: 4%Medication pump implantation: 4% Medication management: 100%Medication management: 100% Physical therapy: 40%Physical therapy: 40% –TENS unit: 6% Occupational therapy: 38%Occupational therapy: 38% Cognitive behavioral therapy: 25%Cognitive behavioral therapy: 25% Nerve blocks: 8%Nerve blocks: 8% Medication pump implantation: 4%Medication pump implantation: 4%

13. Polytrauma Pain Outcomes Reduced prescription of opioid pain medicationsReduced prescription of opioid pain medications –58% at admission vs 48% at discharge Increased use of NSAIDS at dischargeIncreased use of NSAIDS at discharge Reduced prescription of opioid pain medicationsReduced prescription of opioid pain medications –58% at admission vs 48% at discharge Increased use of NSAIDS at dischargeIncreased use of NSAIDS at discharge

14. Average pain intensity rating at dischargeAverage pain intensity rating at discharge –3.7 (SD: 3.3) –This was significantly lower than t he mean admission score [F(1,27) = 6.681, p =.015] However, pain continues to be a problem at discharge, which puts these patients at increased risk for chronic pain problemsHowever, pain continues to be a problem at discharge, which puts these patients at increased risk for chronic pain problems Average pain intensity rating at dischargeAverage pain intensity rating at discharge –3.7 (SD: 3.3) –This was significantly lower than t he mean admission score [F(1,27) = 6.681, p =.015] However, pain continues to be a problem at discharge, which puts these patients at increased risk for chronic pain problemsHowever, pain continues to be a problem at discharge, which puts these patients at increased risk for chronic pain problems Polytrauma Pain Outcomes

15. Chronic Pain Risk Factors If pain continues after the post- acute phase, there is then risk for developing chronic painIf pain continues after the post- acute phase, there is then risk for developing chronic pain –Approximately 30% of patients who experience acute pain progress to chronic pain (Von Korff & Saunders, 1996) If pain continues after the post- acute phase, there is then risk for developing chronic painIf pain continues after the post- acute phase, there is then risk for developing chronic pain –Approximately 30% of patients who experience acute pain progress to chronic pain (Von Korff & Saunders, 1996)

16. Chronic Pain Risk Factors Polytrauma patients are at even greater risk for developing chronic pain problems givenPolytrauma patients are at even greater risk for developing chronic pain problems given –Continued pain despite rehabilitation –Complex/multiple injuries –Recurrent medical procedures/surgeries –Psychosocial factors affected by the pain (Shipton et al., 2005, Sondenaa et al., 2001) Polytrauma patients are at even greater risk for developing chronic pain problems givenPolytrauma patients are at even greater risk for developing chronic pain problems given –Continued pain despite rehabilitation –Complex/multiple injuries –Recurrent medical procedures/surgeries –Psychosocial factors affected by the pain (Shipton et al., 2005, Sondenaa et al., 2001)

17. Clinical Implications Pain needs to be consistently assessed, treated, and documented (at least once per shift or outpatient visit) across the continuum of rehabilitation care Pain needs to be consistently assessed, treated, and documented (at least once per shift or outpatient visit) across the continuum of rehabilitation care Polytrauma patients are at potential risk for the development of chronic pain and CPS Polytrauma patients are at potential risk for the development of chronic pain and CPS Aggressive multidisciplinary pain management incorporating medical and behavioral pain specialists is needed Aggressive multidisciplinary pain management incorporating medical and behavioral pain specialists is needed Pain needs to be consistently assessed, treated, and documented (at least once per shift or outpatient visit) across the continuum of rehabilitation care Pain needs to be consistently assessed, treated, and documented (at least once per shift or outpatient visit) across the continuum of rehabilitation care Polytrauma patients are at potential risk for the development of chronic pain and CPS Polytrauma patients are at potential risk for the development of chronic pain and CPS Aggressive multidisciplinary pain management incorporating medical and behavioral pain specialists is needed Aggressive multidisciplinary pain management incorporating medical and behavioral pain specialists is needed

18. Research Implications Evaluation of long term pain outcomes in polytrauma patientsEvaluation of long term pain outcomes in polytrauma patients Development and evaluation of valid pain assessment measures for cognitively impaired polytrauma patientsDevelopment and evaluation of valid pain assessment measures for cognitively impaired polytrauma patients Development and evaluation of education or policy initiatives designed to improve the consistency of assessment and treatment across the continuum of careDevelopment and evaluation of education or policy initiatives designed to improve the consistency of assessment and treatment across the continuum of care Evaluation of long term pain outcomes in polytrauma patientsEvaluation of long term pain outcomes in polytrauma patients Development and evaluation of valid pain assessment measures for cognitively impaired polytrauma patientsDevelopment and evaluation of valid pain assessment measures for cognitively impaired polytrauma patients Development and evaluation of education or policy initiatives designed to improve the consistency of assessment and treatment across the continuum of careDevelopment and evaluation of education or policy initiatives designed to improve the consistency of assessment and treatment across the continuum of care

19. Conclusions Evaluation and management of pain in OIF/OEF soldiers is a challenge for the VA due toEvaluation and management of pain in OIF/OEF soldiers is a challenge for the VA due to –Protracted nature of the OIF and OEF conflicts –Lengthy and multiple deployment episodes –Preponderance of blast injuries –Enhanced survival rates –Interactions between PTSD, other mood disorders –Rapid changes in and need for specialized clinical care, with a paucity of research –Long range of continuum of medical care –Need for multidisciplinary pain management Evaluation and management of pain in OIF/OEF soldiers is a challenge for the VA due toEvaluation and management of pain in OIF/OEF soldiers is a challenge for the VA due to –Protracted nature of the OIF and OEF conflicts –Lengthy and multiple deployment episodes –Preponderance of blast injuries –Enhanced survival rates –Interactions between PTSD, other mood disorders –Rapid changes in and need for specialized clinical care, with a paucity of research –Long range of continuum of medical care –Need for multidisciplinary pain management