screening for acute factors that predict pain post trauma: a pilot study
DESCRIPTION
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. Aims. Test a model of screening for pain and psychological risk factors in a trauma setting - PowerPoint PPT PresentationTRANSCRIPT
Screening for Acute Factors That Predict Pain Post Trauma:
A Pilot Study
Allyson Browne, Kim Fong, Sudhakar Rao, Fiona Wood, Stephan Schug
Royal Perth HospitalUniversity of Western Australia
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
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)
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)
Predicting Pain Post Trauma Study Group &
Trauma PopulationsFollow-Up Number
(% attrition)
Time Frame
Acute Predictors Outcomes Outcome Measures
Williamson et al (2009)
Orthopaedic
1290 (45%)*
*% of available sample
6 Mo Low 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 years Low 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
2 Years
PTSD but not Pain
Depression but not Anxiety
Physical Fn
Physical Role
Pain
Physical Fn
SF 36
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
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 topredict pain symptom severity post trauma.
Sterling et al (2005) Jenewein et al (2009)
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)
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
Methods
All new trauma admissions identified with LOS > 24 hrs.
Excluded:Moderate/Severe Head Injury
PTA > 24 hrs or GCS < 13 at admissionSevere ETOH DependenceHigh Suicidal RiskOverseas or Interstate Visitor
Non-English Speaking
Risk Screening within 1 Month Post Injury: Medical file reviewSemi-Structured Clinical Interviews Standardised self report measures
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
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.
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
Fall9%
MVA41%
MBA29%
Assault7%
Other4%
Work4%
Sport6%
Mechanism of Injury
Clinical Characteristics
Upper Limb4%
Lower Limb27%
Back4%
Chest4%
Spinal12%
Internal4%
Pelvis8%
Face5%
Multi32%
Type of Injury
• 72% (n = 92) Surgery
• 92 % (n = 87) GA
• 4% (n = 5) Amputation
• 11.7% Wound Infection
• 30% ETOH related injury
Baseline Pain & Psychological Factors
20.4
49.3
15
51.4
40.1
26.8
47.7
0
10
20
30
40
50
60
Neuro
pathic
Pai
n
Moder
ate/
Sever
e Ave
rage
Pain
Low Pai
n Confid
ence
At Ris
k PTSD/D
epre
ssio
n
Depre
ssiv
e sy
mpt
oms
PTSD s
ympto
ms
Harm
ful E
TOH U
se
%
Baseline & 6 Month Findings
20.4
49.3
15
40.1
26.8
47.7
12.3
30.8
12.9
32.3
21.5
30.2
0
10
20
30
40
50
60
%
Baseline
Six Months
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.
Predicting PTSD at 6 Months
Final Step and Acute Predictors β t ∆R2 ∆F
2.2. Age Age GenderGender Injury SeverityInjury Severity Trial GroupTrial Group Acute Traumatic StressAcute Traumatic Stress Acute DepressionAcute Depression Posttraumatic Adjustment Alcohol Use Average Pain Severity Neuropathic symptoms
.10.10
.10.10-.02-.02-.02-.02.13.13.04.04.51.38-.40.22
1.281.281.311.31-.20-.20-.27-.271.271.27.38.38
5.08***4.82***-5.05***
2.54*
.70.70 .22.85***.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.
Predicting Pain at 6 MonthsFinal Step and Predictors β t ∆R2 ∆F
2.2. Age Age GenderGender Injury SeverityInjury Severity Trial GroupTrial Group Acute Traumatic StressAcute Traumatic Stress Acute DepressionAcute Depression Posttraumatic Adjustment Alcohol UseAlcohol Use Average Pain SeverityAverage Pain Severity Neuropathic symptoms
-.03-.03-.17-.17-.08-.08-.09-.09.03.03-.23-.23.33.15.15.07.07.33
-.22-.22-1.38-1.38-.61-.61-.70-.70.21.21
-1.32-1.322.02*1.161.16.55.55
2.44*
.27.27 3.24*3.24*
*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.
Predicting Physical Function at 6 Months
Final Step and Acute Predictors β t ∆R2 ∆F
2.2. Age Age GenderGender Injury Severity Trial GroupTrial Group Acute Traumatic StressAcute Traumatic Stress Acute DepressionAcute Depression Posttraumatic Adjustment Average Pain Severity Alcohol UseAlcohol Use
-.14-.14.03.03-.34..0909.16.16-.36-.36-.49.44.10.10
-1.12-1.12.21.21
-2.81*.80.80.99.99
-2.12-2.12-3.10**3.47**
.79.79
.45.45 6.75***6.75***
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
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
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?
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?
Dr Allyson BrowneDr Allyson [email protected] of Western AustraliaUniversity of Western Australia