Current views on acute to chronic pain transition in post-traumatic patients: risk factors and potential for pre-emptive treatments

Increased Incidence of Depression and Chronic Pain in Traumatic Spinal Cord Injury Patients With Pre-Injury Alcohol Use Disorder: Longitudinal Analysis of Insurance Claim Database

Alcohol use disorder (AUD) increases risk of traumatic spinal cord injury (SCI) and is associated with depression, anxiety, and chronic pain. Given that these neuropsychiatric morbidities are frequently observed in SCI patients, the effects of pre-injury AUD on risk of depression, anxiety, or chronic pain were analyzed using an insurance claim database. Of 10,591 traumatic SCI patients, 507 had AUD-associated claims in a 12-month period before injury. Those AUD-positive SCI patients showed distinct demographic characteristics, including greater representation of men, younger age, more comorbidities, lower coverage by commercial insurance, and more cervical-level injuries. The AUD group also showed elevated pre-injury comorbidity of depression, anxiety, and chronic pain. However, multi-regression analysis revealed an increased odds ratio (OR) of de novo diagnosis of post-SCI depression in AUD patients 6 months (1.671; 95% confidence interval [CI]: 1.124, 2.483) and 1 year post-injury (1.511; 95% CI: 1.071, 2.131). The OR of de novo post-SCI anxiety was unaffected by pre-injury AUD. Finally, 1 year after SCI, pre-injury AUD increased the OR of de novo diagnosis of post-injury chronic pain (1.545; 95% CI: 1.223, 1.951). Thus, pre-injury AUD may be a risk factor for development of depression and chronic pain after traumatic SCI.

Regional anesthesia in trauma patients: a quality improvement study

BACKGROUND

Traumatic injury is associated with severe pain that is often inadequately managed. Opioids remain the mainstay of pain management in this population because of their ease of use. However, opioids have significant side effects including nausea, delirium, and respiratory depression. Regional anesthesia has been demonstrated in the perioperative setting to provide superior analgesia with fewer side effects and a reduced length of stay. Similarly, regional anesthesia has been shown to improve morbidity for extremity fractures and dislocations when introduced early.

METHODS

This was a prospective cohort quality improvement study evaluating the use of earlier and more consistent regional anesthesia procedures in 28 consecutive trauma patients at a large Canadian trauma center. In this quasi-experimental before and after study, we identified all trauma patients with an ISS < 15 that would have been candidates for a peripheral nerve block and compared them to the study population that received a regional anesthesia nerve block within 24 h of admission.

RESULTS

The introduction of a multidisciplinary pain program into our level 1 regional trauma center resulted in a decrease in pain severity and opioid consumption of 55% and 61%, respectively, after 24 h of admission. Length of stay in the emergency department decreased (11.5 ± 6.9 vs. 4.9 ± 4.4 h; p < 0.01) while hospital length of stay did not (338 ± 276 vs. 285 ± 205 h; p = 0.4).

CONCLUSION

This quality improvement proof-of-principle study reveals the potential advantages for regional anesthesia, such as decreased emergency department use, opioid consumption, and pain severity. Further randomized trials are necessary, however, to describe a direct benefit from peripheral nerve blockade on reducing length of stay for trauma patients.

Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion

It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.

"Persistent Post-Operative Pain in Children - An Argument for a Transitional Pain Service in Pediatrics"

BACKGROUND

Persistent post-operative pain continues to occur in pediatric patients. Despite the growing amount of literature on causes, there is little discussion on treatment and prevention with a majority of studies focusing on specific surgeries.

AIM

The aim of this retrospective chart study is to identify risk factors and clinical features of persistent post-operative pain after any surgery in a pediatric quaternary complex pain service, describe the pharmacologic and non-pharmacologic management in children, and explore options to improve outcomes, in particular, the introduction of a transitional pain service.

METHODS

A retrospective chart review recorded demographics, gender, age, pain location and surgery type, treatment, and outcomes of 31 children identified through relevant registers over a 2-year period.

RESULTS

A total of 31 children were positively identified as having persistent post-operative pain and were seen in the complex pain clinic. Consistent with the literature, most cases represented neuropathic pain and persistent post-operative pain was most commonly seen after orthopedic surgery. All but four children had resolution of their pain after implementing the pain management plan. Management was characterized by early intervention, emphasis on non-pharmacologic strategies, and conservative use of opioids.

CONCLUSIONS

Identifying risk factors is useful, however putting strategies into place for prevention is necessary. Early intervention and the implementation of strategies before and immediately after are best provided by a transitional pain service.

Regional anesthesia and analgesia for trauma: an updated review

PURPOSE OF REVIEW

This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain.

RECENT FINDINGS

In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes.

SUMMARY

Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.

Risk Factors to Persistent Pain Following Musculoskeletal Injuries: A Systematic Literature Review

Background: Musculoskeletal (MSK) injury is one of the major causes of persistent pain. Objective: This systematic literature review explored the factors that lead to persistent pain following a MSK injury in the general population, including athletes. Methods: A primary literature search of five electronic databases was performed to identify cohort, prospective, and longitudinal trials. Studies of adults who diagnosed with a MSK injury, such as sprains, strains or trauma, were included. Results: Eighteen studies involving 5372 participants were included in this review. Participants’ ages ranged from 18–95 years. Most of the included studies were of prospective longitudinal design. Participants had a variety of MSK injuries (traumatic and non-traumatic) causing persistent pain. Multiple factors were identified as influencing the development of persistent pain following a MSK injury, including high pain intensity at baseline, post-traumatic stress syndrome, presence of medical comorbidities, and fear of movement. Scarcity of existing literature and the heterogeneity of the studies made meta-analysis not possible. Conclusions: This systematic review highlighted factors that might help predict persistent pain and disability following MSK injury in the general population, including athletes. Identification of these factors may help clinicians and other health care providers prevent the development of persistent pain following a MSK injury.

Relevance of Sleep Disturbances to Orthopaedic Surgery: A Current Concepts Narrative and Practical Review

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Sleep disturbances can increase the risk of falls and motor vehicle accidents and may reduce bone density.

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Poor sleep can lead to worse outcomes after fracture, such as chronic pain and delayed recovery.

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Orthopaedic surgeons can play an important role in the screening of sleep disorders among their patients.

Recognising and assessing acute pain

This article considers two areas of practice that are fundamental to the provision of high-quality nursing care for people experiencing acute pain: the initial recognition of pain, and the formal assessment of pain. The initial recognition of a patient's pain is a subject that is frequently overlooked in the literature. However, if nurses are unable to identify that a patient is experiencing pain, then a formal pain assessment may not take place, which in turn negatively affects the quality of any subsequent pain management. This article explores some of the barriers to the initial recognition of pain and examines how a formal pain assessment can support optimal patient care.

Chronic Pain following Chest Trauma: Prevalence, Associated Factors, and Psychosocial Impact

Background

Chronic pain (CP) is a real public health concern. It is a common cause of poor quality of life and workplace absenteeism. It is well studied in many medical and surgical fields. However, only few data are available as regards to its occurrence in trauma patients.

Purpose

To assess the prevalence, associated factors, and psychosocial impact of CP following chest trauma.

Methods

This is an observational, descriptive, and analytic cross-sectional study performed in a Tunisian department of anesthesia and intensive care over a two-month period. Adult patients admitted one year ago for isolated chest trauma were enrolled. Data were collected by a phone interview. Studied variables were sociodemographic characteristics, traumatic injuries and their management, the occurrence of CP, and its psychosocial impact. CP was diagnosed by the Brief Pain Inventory (BPI) considering an evolution period of at least 3 months. Its impact was assessed by the BPI and the Posttraumatic stress disorder Checklist Scale (PCLS).

Results

Fifty-four patients were included in the study. The prevalence of CP was 79.6%. The average CP intensity was 3.18 ± 1.4. It was neuropathic in 90.7%. Its main associated factors were pleural effusion (p=0.016), time to ICU admission (p=0.016), time to ICU admission (p=0.016), time to ICU admission (p=0.016), time to ICU admission (.

Conclusion

CP following chest trauma is frequent and severe requiring preventive measures such as high risk patients screening, better management of acute pain, and a multidisciplinary approach for patients with diagnosed CP.

An Evaluation of Navy En Route Care Training Using a High-Fidelity Medical Simulation Scenario of Interfacility Patient Transport

INTRODUCTION

Military prehospital and en route care (ERC) directly impacts patient morbidity and mortality. Provider knowledge and skills are critical variables in the effectiveness of ERC. No Navy doctrine defines provider choice for patient transport or requires standardized provider training. Frequently, Search and Rescue Medical Technicians (SMTs) and Navy Nurses (ERC RNs) are tasked with this mission though physicians have also been used. Navy ERC provider training varies greatly by professional role. Historically, evaluations of ERC and patient outcomes have been based on retrospective analyses of incomplete data sets that provide limited insight on ERC practices. Little evidence exists to determine if current training is adequate to care for the most common injuries seen in combat trauma patients.

MATERIALS AND METHODS

Simulation technology facilitates a standardized patient encounter to enable complete, prospective data collection while studying provider type as the independent variable. Information acquired through skill performance observation can be used to make evidence-based recommendations to improve ERC training. This IRB approved multi-center study funded through a Congressionally Directed Medical Research Program grant from the Combat Casualty Care Intramural Research Joint En Route Care portfolio evaluated Navy ERC providers. The study evaluated 84 SMT, ERC RN, and physician participants in the performance of critical and secondary actions during an immersive, high-fidelity, patient transport simulation scenario focused on the care during an interfacility transfer. Simulation evaluators with military ERC expertise, blinded to participant training and background, graded each participant's performance. Inter-rater reliability was calculated using Cohen's Kappa to evaluate concordance between evaluator assessments. Categorical data were reported as frequencies and percentages. Performance attempt and accuracy rates were compared with likelihood ratio chi-square or Fisher's exact test where appropriate. Tests were two-tailed and we considered results significant, that is, a difference not likely due to chance exists between groups, if p < 0.05. Confidence intervals were used to present overlap in performance between provider types.

RESULTS

Critical and secondary actions were assessed. A majority of providers completed at least one of the critical life-saving actions; only one participant completed all critical actions. Evaluation of critical actions demonstrated that a tourniquet was applied by 64% of providers, blood products administered by 46%, needle decompression performed by 51%, and a complete handoff report performed by 48%. Assessment of secondary actions demonstrated analgesic was accurately administered by 24% of all providers, and 44% reinforced the "hemorrhaging amputation site dressing."

CONCLUSION

Over 98% of participants failed to properly perform all critical actions during the interfacility transfer scenario, which in a real-life combat casualty transport scenario could result in a preventable death. Study results demonstrate serious skill deficits among all types of Navy ERC providers. These data can be used to improve the training of Navy ERC providers, ultimately improving care to injured soldiers, sailors, airmen, and marines.

Influencing walking behavior can increase the physical activity of patients with chronic pain hospitalized for multidisciplinary rehabilitation: an observational study

Background

Physical therapy and exercising are key components of biopsychosocial rehabilitation for chronic pain. Exercise helps reduce pain and improve physical functions. In addition, a high level of physical activity benefits quality of life and emotional well-being. However, the degree to which hospitalization for extensive rehabilitation effectively increases physical activity has not yet been studied. Therefore, we investigated the physical activity level and the walking behavior of inpatients with musculoskeletal pain. The objectives were 1) to compare physical activity level and walking with or without rehabilitation, 2) to evaluate whether pain site influences physical activity level, and 3) to measure the association between physical activity and pain-related interference with physical functioning.

Methods

During a rehabilitation stay, 272 inpatients with lower limb, spine, or upper limb pain wore an accelerometer over 1 week. We assessed the daily duration of the practice of moderate physical activity and walking. Weekend days, during which the participants went home (days off), were used as a reference for habitual activities. We also evaluated 93 patients before the hospitalization to validate the use of days off as a baseline. Pain interference was measured with the brief pain inventory questionnaire. Generalized linear mixed models analyzed the association between physical activity and walking levels, and 1) rehabilitation participation, 2) pain sites, and 3) pain interference.

Results

Weekend days during the stay have similar physical activity level as days measured before the stay (73 min / day at the clinic, versus 70 min / day at home). Rehabilitation days had significantly higher physical activity levels and walking durations than days off (+ 28 min [+ 37%] and + 32 min [+ 74%], respectively). Mixed models revealed 1) a negative association between physical activity and pain interference, and 2) no effect of pain sites. Overall, patients increased their physical activity level independently of reported pain interference.

Conclusions

Despite their painful condition, the inpatients were able to engage themselves in a higher level of physical activity via increased participation in walking activities. We conclude that walking incentives can be a valid solution to help patients with chronic pain be more physically active.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2561-9) contains supplementary material, which is available to authorized users.

Pain with traumatic brain injury and psychological disorders

Traumatic brain injury (TBI) is the cause for long-term disability in more than 3 million patients in the US alone, with chronic pain being the most frequently reported complain. To date, predisposing mechanisms for chronic pain in TBI patients are largely unknown. Psychological disorders, including post-traumatic stress disorder, depression and anxiety following TBI are commonly reported comorbidities to post-traumatic pain. Long term consequences can be debilitating and affect quality of life even when the injury is mild. In this review, we present the most commonly reported chronic pain conditions across the spectrum of severity of TBI, mainly focusing on mild TBI. We discuss chronic post- traumatic headaches, widespread pain as well as post-traumatic central pain. We discuss pain in the context of injury severity and military versus civilian populations. We are only starting to understand the biological mechanisms behind post-traumatic pain and associated psychological distress following TBI, with genetic, biochemical and imaging studies pointing to the dopaminergic, neurotrophic factors and the role of Apolipoprotein. Physiological and neurological mechanisms are proposed to partially explain this interaction between post-traumatic pain and psychological distress. Nevertheless, the evidence for the role of structural brain damage remains incomplete and to a large extent debatable, as it is still difficult to establish clear causality between brain trauma and chronic pain. Finally, general aspects of management of chronic pain post-TBI are addressed.

Early Factors Associated with the Development of Chronic Pain in Trauma Patients

Objective

To identify factors, available at the time of trauma admission, associated with the development of chronic pain to allow testing of preventive approaches.

Methods

In a retrospective observational cohort study, we included all patients ≥ 18 years old admitted for injury in 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014. Chronic pain was defined as follows: treated in a chronic pain clinic, diagnosed with chronic pain, or received at least 2 prescriptions of chronic pain medications 3 to 12 months postinjury.

Results

A total of 95,134 patients were retained for analysis. Mean age was 59.8 years (±21.7), and 52% were men. The causes of trauma were falls (63%) and motor vehicle accidents (22%). We identified 14,518 patients (15.3%; 95% CI: 15.1–15.5) who developed chronic pain. After controlling for confounding factors, the variables associated with chronic pain were spinal cord injury (OR = 3.9; 95% CI: 3.4–4.6), disc-vertebra trauma (OR = 1.6; 95% CI: 1.5–1.7), history of alcoholism (OR = 1.4; 95% CI: 1.2–1.7), history of anxiety (OR = 1.4; 95% CI: 1.2–1.5), history of depression (OR = 1.3; 95% CI: 1.1–1.4), and being female (OR = 1.3; 95% CI: 1.2–1.3). The area under the receiving operating characteristic curve derived from the model was 0.80.

Conclusions

We identified risk factors present on hospital admission that can predict trauma patients who will develop chronic pain. These factors should be prospectively validated.

The Role of Negative Affect on Headache-Related Disability Following Traumatic Physical Injury

OBJECTIVE

Acute postinjury negative affect (NA) may contribute to headache pain following physical injury. Early psychiatric-headache comorbidity conveys increased vulnerability to chronic headache-related disability and impairment. Yet, it is unknown whether NA is involved in the transition to chronic headache related-disability after injury. This prospective observational study examined the role of acute postinjury NA on subacute and chronic headache-related disability above and beyond nonpsychiatric factors.

METHODS

Eighty adult survivors of single-incident traumatic physical injury were assessed for negative affect (NA): a composite of depression and anxiety symptoms, and symptoms of posttraumatic stress disorder (PTSS) during the acute 2-week postinjury phase. NA was examined as the primary predictor of subacute (6-week) and chronic (3-month) headache-related disability; secondary analyses examined whether the individual NA components differentially impacted the outcomes.

RESULTS

Hierarchical linear regression confirmed NA as a unique predictor of subacute (Cohen's f ²  = 0.130; P = .005) and chronic headache related-disability (Cohen's f ²  = 0.160; P = .004) beyond demographic and injury-related factors (sex, prior headaches, and closed head injury). Upon further analysis, PTSS uniquely predicted greater subacute (Cohen's f ²  = 0.105; P = .012) and chronic headache-related disability (Cohen's f ²  = 0.103; P = .022) above and beyond demographic and injury-related factors, depression, and anxiety. Avoidance was a robust predictor of subacute headache impairment (explaining 15% of the variance) and hyperarousal was a robust predictor of chronic headache impairment (10% of the variance).

CONCLUSION

Although NA consistently predicted headache-related disability, PTSS alone was a unique predictor above and beyond nonpsychiatric factors, depression, and anxiety. These results are suggestive that early treatment of acute postinjury PTSS may correlate with reductions in disability and negative physical health sequelae associated with PTSS and chronic headache.

Post-concussion symptoms and chronic pain after mild traumatic brain injury are modulated by multiple locus effect in the BDNF gene through the expression of antisense: A pilot prospective control study

Background: Mild traumatic brain injury (mTBI) often results in post-concussion symptoms, chronic pain, and sleepiness. Genetic factors are thought to play an important role in poor prognosis.

Aims: The aims of this study are to (1) document the prevalence of pain and post-concussion symptoms in mTBI patients in acute and chronic phases (2) determine whether candidate genes predispose to post-concussive symptoms and pain.

Methods: Posttraumatic symptoms, evaluated using the Rivermead Post-Concussion Symptoms Questionnaire, and pain were assessed in 94 mTBI patients in the acute phase as well as in 22 healthy controls. Assessment was repeated in 36 patients after one year who agreed to participate in the follow-up visit. Gene polymorphisms and expression were assessed in mTBI patients and healthy controls.

Results: In the acute phase, mTBI patients with pain (69%) presented more psychological symptoms and sleepiness and were less able to return to work than those without pain. At one year, 19% of mTBI patients had persistent pain and psychological distress. Two haplotypes (H2 and H3) in the brain-derived neurotrophic factor (BDNF) gene were shown to be respectively deleterious and protective against post-concussion symptoms and pain in both acute and chronic phases. Protective haplotype H3 was associated with a decreased expression of the anti-sense of BDNF (BDNF-AS). Deleterious haplotype H2 predicted the development of chronic pain at one year, whereas H3 was protective.

Conclusions: This pilot study suggests a protective mechanism of a multilocus effect in BDNF, through BDNF-AS, against post-concussion symptoms and pain in the acute phase and possibly chronic pain at one year post-mTBI. The role of antisense RNA should be validated in larger cohorts.

Characteristics of Patients with Lower Extremity Trauma with Improved and Not Improved Pain During Hospitalization: A Pilot Study

Up to 62% of patients report chronic pain at the injury site 6-12 months after blunt trauma, with pain from lower extremity fractures exceeding that from other sites. High pain intensity at time of injury is a risk factor for chronic pain, but it is not clear what patient characteristics influence the pain intensity level during the immediate hospitalization following injury. The purpose of this pilot study was to determine the feasibility of collecting pain scores from medical records to calculate pain trajectories and to determine whether it is possible to examine patient characteristics by classifying them into those whose pain improved and those whose pain did not improve. This descriptive study retrospectively reviewed medical records of 18 randomly chosen patients admitted to an academic trauma center. Patient characteristics and pain scores were collected form electronic and handwritten medical records. The pain trajectories calculated from routinely collected pain scores during the inpatient stay showed that for 44% of patients the pain improved during the hospitalization, for 39% the pain remained the same, and for 17% the pain worsened. The variables age, smoking, weight, abbreviated injury scores, length of hospital stay, mean pain score, and opioid equianalgesic dose differed based on pain trajectory. While patient characteristics differed based on pain trajectory, any significant effects seen from individual tests should be considered tentative, given the number of analyses conducted on this data set. However, feasibility and significance of conducting a larger study has been established.

Regional anesthesia for the trauma patient: improving patient outcomes

Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.