Pain management in the traumatic amputee

Approaching trauma analgesia using prolonged and novel continuous peripheral nerve blocks - A case report

Background

A supraclavicular brachial plexus nerve block provides analgesia for the shoulder, arm, and hand; however, the maximum safe duration for a continuous infusion remains controversial. A novel continuous peripheral nerve block (CPNB) technique combining the Lateral, Intermediate, and Medial femoral cutaneous nerves (termed the ‘LIM’ block) to provide analgesia to the lateral, anterior, and medial cutaneous areas of the thigh while preserving quadriceps strength will also be described in detail here.

Case

We present a complex case in which simultaneous utilization of an unilateral supraclavicular CPNB (5 weeks) and bilateral LIM CPNB (5 days) are successfully performed to provide analgesia for a traumatic degloving injury resulting in multiple surgeries.

Conclusions

The analgesic plan in this case study eliminated previous episodes of opioid-induced delirium, facilitated participation in recovery, and removed concerns for respiratory depression and chronic opioid use in a patient at particular risk for both issues.

Posttraumatic stress disorder symptom clusters and substance use among patients with upper limb amputations due to traumatic injury

Purpose: Examining the relationship between posttraumatic stress disorder and posttraumatic stress disorder symptom clusters (re-experiencing, avoidance, hyperarousal, emotional numbing) on three substance use measures among individuals with upper limb amputation due to traumatic injury - an understudied population with high rates of posttraumatic stress disorder.Methods: Multi-site, cross-sectional design. Participants (N = 236) were recruited from seven prosthetic rehabilitation centres across the USA and completed measures of PTSD, alcohol use, prescription medication overuse, and illicit drug use.Results: Twenty-six percent of participants screened positive for posttraumatic stress disorder, 39% for problematic alcohol use, 12% for prescription medication overuse, and 7% for illicit drug use. No association was found between posttraumatic stress disorder or posttraumatic stress disorder symptoms clusters on problematic alcohol use. However, hyperarousal symptoms increased odds of overusing prescription medication (odds ratio = 3.30); further, a positive screen for posttraumatic stress disorder increased odds of illicit drug use (odds ratio = 2.95).Conclusions: These findings demonstrate the importance of assessing psychological well-being and a variety of substance use behaviours following amputation from traumatic injury. These findings may also provide clinically-relevant targets for prevention and intervention regarding prescription medication and illicit substance use, such as incorporating evidence-based treatment for posttraumatic stress disorder hyperarousal symptoms (e.g., prolonged exposure) and/or integrated treatment for posttraumatic stress-substance misuse (e.g., Seeking Safety) into patients' long-term inpatient/outpatient rehabilitation plans.Implications for rehabilitationPosttraumatic stress disorder hyperarousal symptoms increased odds of overusing prescription medication among individuals with upper limb amputation due to traumatic injury; a positive screen for posttraumatic stress disorder increased odds of illicit drug use.Psychological assessments should be incorporated into treatment and rehabilitation plans following amputation from traumatic injury.Rehabilitation specialists should consider adding or integrating evidence-based treatment for posttraumatic stress disorder into patients' long-term rehabilitation plan to reduce risk for problematic substance use.Findings support calls by the Centre for Disease Control and Prevention to overhaul prescription medication guidelines, including the need to assess risk and address harms concerning overuse of prescription medication.

Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. A systematic search of Medline, CINAHL, and Index to Chiropractic Literature was performed from inception through April 2015. Thirty articles met inclusion criteria. Studies reporting utilization and policy show that chiropractic services are successfully implemented in various military and veteran health care settings and that integration varies by facility. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.

Challenging the catechism of therapeutics for chronic neuropathic pain: Targeting CaV2.2 interactions with CRMP2 peptides

Chronic neuropathic pain management is a worldwide concern. Pharmaceutical companies globally have historically targeted ion channels as the therapeutic catechism with many blockbuster successes. Remarkably, no new pain therapeutic has been approved by European or American regulatory agencies over the last decade. This article will provide an overview of an alternative approach to ion channel drug discovery: targeting regulators of ion channels, specifically focusing on voltage-gated calcium channels. We will highlight the discovery of an anti-nociceptive peptide derived from a novel calcium channel interacting partner - the collapsin response mediator protein 2 (CRMP2). In vivo administration of this peptide reduces pain behavior in a number of models of neuropathic pain without affecting sympathetic-associated cardiovascular activity, memory retrieval, sensorimotor function, or depression. A CRMP2-derived peptide analgesic, with restricted access to the CNS, represents a completely novel approach to the treatment of severe pain with an improved safety profile. As peptides now represent one of the fastest growing classes of new drugs, it is expected that peptide targeting of protein interactions within the calcium channel complex may be a paradigm shift in ion channel drug discovery.

Short-term physical and mental health outcomes for combat amputee and nonamputee extremity injury patients

OBJECTIVES

The present study: (1) reports the early physical health complications, mental health outcomes, and outpatient health care utilization of patients with serious extremity injuries sustained during the Iraq or Afghanistan wars and (2) compares clinical outcomes between amputee and nonamputee extremity injury groups.

METHOD

This was a retrospective review of clinical records in military health databases for patients injured in the Iraq and Afghanistan wars. Health outcomes of amputee (n = 382, injured 2001-2005) and nonamputee patients (n = 274, injured 2001-2007) with serious extremity injuries (abbreviated injury score ≥ 3) were followed up to 24 months post injury. This study was performed at Naval Health Research Center, San Diego.

RESULTS

Amputee and nonamputee groups had similar injury severity scores. Amputees had nearly double the risk of certain adverse complications (infections, anemia, septicemia, and thromboembolic disease), but other complications (osteomyelitis and nonhealing wound) were similar between the 2 groups. Amputees had significantly greater odds of certain mental health disorders including mood, sleep, pain, and postconcussion syndrome. However, amputees had significantly reduced odds of posttraumatic stress disorder compared with nonamputees. Amputees used various outpatient clinics significantly more than nonamputees.

CONCLUSIONS

Patients with serious combat extremity injuries showed high rates of adverse health outcomes in the short term. Amputees had higher rates of many but not all clinically important physical and mental health outcomes compared to nonamputees. These results are important for military orthopaedic surgeons and allied providers who care for and counsel these patients and clinicians and researchers who seek to understand and improve health outcomes in patients with extremity war injuries.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of gabapentin for treatment of adults with phantom limb pain

OBJECTIVE

To evaluate the effectiveness of gabapentin in adults with phantom limb pain.

DATA SOURCES

A PubMed search (1966-September 2012) was conducted using the key words phantom limb pain and gabapentin. Search limits were English language, humans, adult, clinical trials, and randomized controlled trial.

STUDY SELECTION AND DATA EXTRACTION

Randomized controlled trials that studied the effectiveness of gabapentin in adults with phantom limb pain were identified and selected. Primary outcomes were associated with pain. Pediatric population studies were excluded.

DATA SYNTHESIS

Three studies, with a total of 89 patients, were reviewed. All studies employed a pain rating scale to determine the primary outcome. Results varied. One crossover study reported a significant difference in pain intensity at 6 weeks compared with baseline (p < 0.01) and compared with placebo (p = 0.03). Another crossover study did not find a significant difference for the primary outcome of pain intensity, but did report a significant decrease in a secondary outcome measure related to pain. The third study displayed a decreased use of rescue pain medications by patients in the gabapentin treatment group. Heterogeneity of the study designs precludes a direct comparison of the results. Several confounding factors that may affect the interpretation of these results include the use of rescue pain medication, small sample size, short-term treatment, and different pain scales.

CONCLUSIONS

Given the results of these trials, oral gabapentin in patients aged 18 years or older may decrease phantom limb pain. A strong recommendation for the effectiveness of gabapentin in phantom limb pain cannot be ascertained until more methodologically sound studies are executed in this population.

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and their Efficacy

Chronic pain is the leading cause of disability in the United States. The transition from acute to persistent pain is thought to arise from maladaptive neuroplastic mechanisms involving three intertwined processes, peripheral sensitization, central sensitization, and descending modulation. Strategies aimed at preventing persistent pain may target such processes. Models for studying preventive strategies include persistent post-surgical pain (PPP), persistent post-trauma pain (PTP) and post-herpetic neuralgia (PHN). Such entities allow a more defined acute onset of tissue injury after which study of the long-term effects is more easily examined. In this review, we examine the pathophysiology, epidemiology, risk factors, and treatment strategies for the prevention of chronic pain using these models. Both pharmacological and interventional approaches are described, as well as a discussion of preventive strategies on the horizon.

Integrated musculoskeletal rehabilitation care at a comprehensive combat and complex casualty care program

OBJECTIVE

The purpose of this study is to describe the musculoskeletal rehabilitation model used to care for combat and severely wounded or ill US military service members at an integrated Comprehensive Combat and Complex Casualty Care center located at Naval Medical Center San Diego.

METHODS

Through a collaborative and iterative process, providers from the various services included at the Comprehensive Combat and Complex Casualty Care program developed a description of the integration of services provided at this location.

RESULTS

After construction of the facility in 2007, the program has provided services for approximately 2 years. Eighteen different health care providers from 10 different specialties provide integrated musculoskeletal services, which include primary care, physical therapy, occupational therapy, vestibular therapy, gait analysis, prosthetics, recreational therapy, and chiropractic care. At the time of this writing (early 2009), the program had provided musculoskeletal rehabilitation care to approximately 500 patients, 58 with amputations, from the operational theater, Veterans Affairs, other military treatment facilities, and local trauma centers.

CONCLUSION

The complex nature of combat wounded and polytrauma patients requires an integrated and interdisciplinary team that is innovative, adaptable, and focused on the needs of the patient. This article presents a description of the model and the experiences of our musculoskeletal rehabilitation team; it is our hope that this article will assist other centers and add to the small but emerging literature on this topic.

Understanding amputation

Approximately 134,000 amputations occur annually in the United States, resulting mostly from peripheral vascular disease. The risk of amputation increases with age, peaking among those 85 years of age and older. As a lifesaving and life-defining procedure, amputations result in physical and emotional changes affecting quality of life. Phantom pain is problematic for many patients, and agents approved by the Food and Drug Administration for phantom pain are nonexistent. Pharmacists should be knowledgeable about weight-based dosing as well as patient education guidelines.