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 (PRC’s) 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 • PM&RS 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 PM&R and SCI, SCI and PM&R 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 PM&R • 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

10. Tampa Polytrauma Pain Team • Nursing Staff • Assessment and treatment of pain • Education to patient and family • Psychosocial support • Recreational therapy • Diversional activities

11. 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 Polytrauma Pain Management

12. 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 painNeuropathicPain Aching, Dull sharp, electric Throbbing shooting, stabbing

14. 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

17. 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

19. 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 • Don’t 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