Pain Management in the Severely Impaired Polytrauma Patient Entering Rehabilitation

1
Pain Management in the Severely Impaired
Polytrauma Patient Entering Rehabilitation

• Joel Scholten, MD
• Physical Medicine and Rehabilitation
• James A. Haley Veterans Hospital
• Tampa, Florida

2
The Polytrauma Rehab Center

• The four Polytrauma Rehabilitation Centers
  (PRCs) are inpatient rehabilitation programs
  that have been treating combat related polytrauma
  patients since early 2003.
• The PRCs utilize 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 care

3
The Polytrauma Patient

• Injuries to multiple areas of the body involving
  multiple organ systems resulting in significant
  functional impairment.
• The traumatic brain injury is usually the driving
  factor for rehabilitation.

4
Traditional Rehab Team

• PMRS Attending Physician
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Recreational Therapy
• Psychology
• Nursing
• Prosthetics
• Social Work

5
Polytrauma Team Approach in Tampa

• Traditional Rehabilitation Team Plus
• Multidisciplinary Team Rounds
• Twice weekly multidisciplinary rounds
• Chief of PMR and SCI, SCI and PMR Attending,
  Internal Medicine, Infectious Disease, Surgery,
  Nursing, Infection Control, Case Managers,
  Utilization Review, Pain Management
• Discuss ongoing medical needs, pain management,
  psychosocial issues, military needs

6
Polytrauma Team Approach in Tampa

• Pain Psychologist
• Close interdependent collaboration with PMR
• PTSD Psychologist

7
Tampa Polytrauma Pain Team

• Pain Psychologist
• attends polytrauma medical rounds
• comprehensive documentation of pain problems
• serves on clinical and administrative teams
• provides assessment and treatment services
• offers consultative and educational services to
  staff

8
Tampa Polytrauma Pain Team

• Pain Medical Management Consultation
• pain medication and medication adjustments
• opioid pain medication tapers
• Pain Intervention Consultation
• ESIs, Nerve Blocks, and Pump implantations

9
Tampa Polytrauma Pain Team

• Physicians
• Education
• Medical assessment and treatment of pain
• Chiropractics
• Acupuncture
• Injections
• Physical and Occupational Therapy
• Modalities
• Therapies

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Tampa Polytrauma Pain Team

• Nursing Staff
• Assessment and treatment of pain
• Education to patient and family
• Psychosocial support
• Recreational therapy
• Diversional activities

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Polytrauma Pain Management

• Early and continued treatment
• To minimize likelihood of chronic pain problems
• Multidisciplinary in nature
• Behavioral
• Pain Psychologist
• Therapists
• Nursing
• Family/Friends

• Medical
• R/O and manage causes
• Medications
• Opioid reductions
• Transfer of Rx between MTF and VA

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Polytrauma Pain Management

• Multidisciplinary in nature (continued)
• Interventional
• Needed less frequently than meds and behavioral
• ESIs, Nerve Blocks, Pump Implantations
• Therapies and Modalities
• PT
• OT
• RT
• Acupuncture
• Chiropractics

13
Pain Assessment

• Challenging in Low Level Patients
• Utilize Family and Staff for comprehensive
  assessment of pain and impact on function
• Utilize descriptors to help differentiate type of
  pain
• Musculoskeletal pain NeuropathicPain
• Aching, Dull sharp, electric
• Throbbing shooting, stabbing

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Musculoskeletal Pain

• Spasticity
• ROM and stretching- involve family, therapists
  and nursing
• Modalities- ice, heat
• Renew current meds
• Anti-spasticity meds- dantrolene, baclofen,
  tizanadine
• Botox, Nerve Blocks
• Contractures
• Prevention is key! Range of Motion
• Serial Casting and Bracing/Splints

15
Musculoskeletal Pain

• Heterotopic Ossification (H.O.)- calcification of
  soft tissues
• Elevated alkaline phosphatase
• Bone scan for early diagnosis, plain films are
  positive once significant calcification has
  occurred
• Indocin and Didronel
• Radiation therapy can also be used
• Surgical Resection only when H.O. is mature,
  usually after 18 months

16
Musculoskeletal Pain

• Fractures- missed diagnosis
• Sprains/Strains
• Dislocation/Subluxation
• Impingement
• Skin- decubitis ulcers, etc.
• Stump pain

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Musculoskeletal Pain- Treatment

• Exercise, Range of Motion, Massage
• Modalities- TENS, Ultrasound, Heat, Cold
• Topical Medications- Capsaicin, etc.
• NSAIDS
• Anti-spasticity meds- dantrolene, baclofen,
  tizanadine
• Narcotics
• Acupunture, Chiropractic manipulation

18
Neuropathic Pain

• Peripheral Nerve/Plexus Injury
• Complex Regional Pain Syndrome/RSD
• Central Pain
• Phantom Pain

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Neuropathic Pain- Treatment

• Most medications used for treatment of
  Neuropathic pain do not have FDA approval for
  this use.
• Antidepressants
• Antiepileptic Meds
• TENS
• Modalities-Contrast Baths, etc
• Interventional Techniques- epidural injections,
  sympathetic blocks

20
Pain due to Burns

• Initial Pain Management for Burns includes
  significant amount of narcotic
• During Rehab Phase monitor pain level and
  function, attempt to minimize need for
  breakthrough pain medications

21
Other Pain

• Dont blame pain on the TBI
• Cardiac pain
• Abdominal pathology
• Review mechanism of event and other injuries that
  occurred at the time of the initial event ie.
  Abdominal trauma, etc.

22
Pain Management Goals

• Improve Comfort AND Function
• Correlate Pain Score with Function
• Minimize Cognitive Side Effects
• Avoid Poly-pharmacy
• Assess and monitor effect of intervention
• Involve the Patient and Family