Pain and satisfaction in hospitalized trauma patients: the importance of self-efficacy and psychological distress

Healthcare experiences among adults with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder in the United States

PURPOSE

This cross-sectional mixed-method study examined healthcare experiences among individuals in the US with hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD), genetic connective tissue disorders. We hypothesized that many individuals with these conditions would report low satisfaction with healthcare and low health-related quality of life, and that lower healthcare satisfaction would be related to lower health-related quality of life and self-efficacy for symptom management.

METHODS

Adults living in the US with hEDS or HSD (N= 2125) completed an online survey assessing satisfaction with healthcare, health-related quality of life, and symptom management self-efficacy. Qualitative data also were gathered on desired changes to improve healthcare.

RESULTS

Participants reported low satisfaction with healthcare and lower health-related quality of life and symptom management self-efficacy than norm groups. Lower satisfaction with healthcare was associated with lower health-related quality of life and lower symptom management self-efficacy, ps <.001. The most common desired change to improve healthcare was more knowledge about hEDS and HSD among healthcare professionals.

CONCLUSIONS

U.S. adults with joint hypermobility report negative healthcare experiences and poor health-related quality of life. Future research should explore ways to improve the healthcare experiences and quality of care for individuals with hEDS and HSD.Implications for RehabilitationIndividuals with hypermobility spectrum disorder (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) score worse than the U.S. population on most health-related quality of life domains and symptom management self-efficacy.Individuals with HSD and hEDS report low levels of satisfaction with healthcare compared to norm groups.Participants particularly wanted to see improvements in the level of awareness and education about HSD and hEDS among healthcare professionals, provider attitudes about HSD and hEDS, and healthcare accessibility and convenience.Individuals who were less satisfied with their healthcare reported lower health-related quality of life and lower symptom management self-efficacy, underscoring the importance of improving healthcare experiences.

Inpatient pain alleviation after orthopaedic trauma surgery-are we doing a good job?

PURPOSE

Poor pain alleviation (PPA) after orthopaedic surgery is known to increase recovery time, readmissions, patient dissatisfaction, and lead to chronic postsurgical pain. This study's goal was to identify the magnitude of PPA and its risk factors in the orthopaedic trauma patient population.

METHODS

A single-institution's electronic medical records from 2015 to 2018 were available for retrospective analysis. Inclusion criteria included orthopaedic fracture surgery patients admitted to the hospital for 24 h or more. Collected variables included surgery type, basic demographics, comorbidities, inpatient medications, pain scores, and length of stay. PPA was defined as a pain score of ≥ 8 on at least three occasions 4-12 h apart. Associations between collected variables and PPA were derived using a multivariable logistic regression model and expressed in adjusted odds ratios.

RESULTS

A total of 1663 patients underwent fracture surgeries from 2015 to 2018, and 25% of them reported PPA. Female sex, previous use of narcotics, increased ASA, increased baseline pain score, and younger age without comorbidities were identified as significant risk factors for PPA. Spine procedures were associated with increased risk of PPA, while procedures in the hip, shoulder, and knee had reduced risk. Patients experiencing PPA were less likely to receive NSAIDs compared to other pain medications.

CONCLUSIONS

This study found an unacceptably high rate of PPA after fracture surgery. While the identified risk factors for PPA were all non-modifiable, our results highlight the necessity to improve application of current multimodal approaches to pain alleviation including a more personalized approach to pain alleviation.

Psychological treatments for the management of pain after musculoskeletal injury: a systematic review and meta-analysis

ABSTRACT

Musculoskeletal injury is a leading cause of pain and disability worldwide; 35% to 75% of people experience persistent pain for months and years after injury. Psychological treatments can reduce pain, functional impairment, and psychological distress but are not widely used after injury. This systematic review and meta-analysis (PROSPERO ID: CRD42021236807) aimed to synthesize the literature testing psychological treatments for pain after musculoskeletal injury. We searched EMBASE, MEDLINE, PubMed, PsycINFO, and CENTRAL from inception to May 2022. We extracted participant, treatment, and injury characteristics and primary (eg, pain intensity, functional impairment, depression, anxiety, and PTSD symptoms) and secondary (treatment feasibility and acceptability) outcomes. Twenty-four randomized controlled trials (N = 1966) were included. Immediately posttreatment, people who received psychological treatments (versus any control) reported lower pain intensity (standardized mean differences [SMD] = -0.25, 95% confidence interval [-0.49, -0.02]), functional impairment (SMD = -0.32 [-0.55, -0.09]), and symptoms of depression (SMD = -0.46 [-0.64, -0.29]), anxiety (SMD = -0.34 [-0.65, -0.04]), and PTSD (SMD = -0.43 [-0.70, -0.15]); at 6-month follow-up, only depression symptoms were significantly lower. Included trials varied widely in treatment and injury characteristics. The certainty of evidence was low or very low for most effects and heterogeneity moderate to substantial. Most studies had risk of bias domains judged to be high or unclear. Owing to very low certainty of results, we are unsure whether psychological therapies reduce pain and functional impairment after musculoskeletal injury; they may result in improved depression immediately posttreatment and at follow-up. More research is needed to identify treatments that result in enduring effects.

[Quality of Life and Return to Work Following Rehabilitation - Results of the icfPROreha Study]

BACKGROUND

Not only the severity of an injury, but also bio-psycho-social factors affect health-related quality of life and participation in social life after severe musculoskeletal injuries.

METHODS

Multicentre prospective longitudinal study with follow-up up to 78 weeks after discharge from inpatient trauma rehabilitation. Data were collected using a comprehensive assessment tool. Quality of life was assessed using the EQ-5D-5L, return to work by patients' self-reports and routine data of health insurances. Analyses of the association between quality of life and return to work, change over time in quality of life compared to the general German population and multivariate analyses to predict quality of life were conducted.

RESULT

Of 612 study participants (444 men (72.5%); M=48.5 years; SD 12.0), 502 (82.0%) returned to work 78 weeks after discharge from inpatient rehabilitation. Quality of life improved during rehabilitation treatment from 50.18 to 64.50 (mean of visual analogue scale of EQ-5D-5L) and slightly to 69.38 78 weeks after discharge from inpatient trauma rehabilitation. EQ-5D index was below the values of the general population. In total, 18 factors were selected to predict quality of life 78 weeks after discharge from inpatient trauma rehabilitation. Among others, pain at rest and suspected anxiety disorder at admission had a very strong effect on quality of life. Contextual factors such as therapies after acute care and self-efficacy also had an effect on quality of life 78 weeks after discharge from inpatient rehabilitation.

CONCLUSION

Bio-psycho-social factors affect long-term quality of life of patients with musculoskeletal injuries. Already at the time of discharge from acute treatment and even more at the beginning of inpatient rehabilitation, decisions can be made in order to achieve the best possible quality of life for those affected.

Continuous peripheral nerve blocks for analgesia of ventilated critically ill patients with multiple trauma: a prospective randomized study

BACKGROUND

Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA).

METHODS

Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management.

RESULTS

Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0-41.0]. The consumption of sufentanil at 48h was 725 [465-960] μg/48h versus 670 [510-940] μg/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] μg vs. 480 [352-535] μg (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints.

CONCLUSIONS

CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.

Fatal opioid overdoses geospatially cluster with level 1 trauma centers in Ohio

OBJECTIVE

Ohio is consistently ranked as one of the worst states for opioid overdose deaths. Traumatic injury has been linked to opioid overdose deaths, yet the location of trauma centers has not been explored. We examined whether geospatial clustering occurred between county-level opioid overdose deaths (OODs) and trauma center levels.

METHODS

We obtained 2019 county-level data from the Ohio Department of Health for fatal overdoses from prescription opioids. We obtained the total number of opioid doses prescribed in 2019 per county from the Ohio Automated Rx Reporting System and American College of Surgeons designated trauma center locations within Ohio from their website. We used geospatial analysis to assess if clustering occurred between trauma center level and prescription opioid overdose deaths at a county level.

RESULTS

There were 42 trauma centers located within 21 counties: 7 counties had level 1, and 14 counties had only level 2/level 3. There was no difference in rates of opioid doses prescribed per 100,000 people between counties with level 1 trauma centers and only level 2/level 3. However, prescription OODs rates were significantly higher in counties with level 1 trauma centers (37.6 vs 20, P = .02). Geospatial clustering was observed between level 1 trauma centers and prescription opioid overdose deaths at the county level (P < .01).

CONCLUSION

Geospatial clustering exists between prescription OODs and level 1 trauma center locations in Ohio. Improved at-risk patient identification and targeted community outreach represent opportunities for trauma providers to tackle the opioid epidemic.

The variation of opioid prescription after injury and its association with long-term chronic pain: A multicenter cohort study

BACKGROUND

Opioid overprescription in trauma contributes to the opioid epidemic through diversion of unused pills. Through our study, we sought to do the following: (1) understand the variation in opioid prescription after injury and its relationship to patient and/or clinical variables, and (2) study the relationship between opioid prescribing and long-term pain and analgesic use.

METHOD

Trauma patients with an injury severity score ≥9 admitted to 3 level 1 trauma centers were screened for chronic pain and analgesic use 6 to 12 months postinjury. First, multivariable linear regression models were constructed with "oral morphine equivalents" and "number of opioid pills prescribed" at discharge as dependent variables. The coefficients of determination were calculated to determine how much of the variation in opioid prescription was explained by patient and clinical variables. Second, a multivariable logistic regression analysis was created to study the association between opioid prescription at discharge and chronic pain/analgesic use at 6 to 12 months. Analyses were adjusted for patient demographics, socioeconomics, comorbidities, injury parameters, and hospital course.

RESULTS

Of the 2,702 patients included (mean [standard deviation] age: 61.0 [21.5]; 55% males), 74% were prescribed opioids at discharge (mean number of pills [standard deviation]: 24.0 [26.5]; mean oral morphine equivalent [standard deviation]: 204.8 [348.1]). The adjusted coefficients of determination for oral morphine equivalents and number of pills was 0.12 and 0.21, respectively, suggesting that the measured patient and clinical factors explain <21% of the variation in opioid prescribing in trauma. Patients prescribed opioids were more likely to have chronic pain (odds ratio [95%] confidence interval: 1.34 [1.05-1.71]) and use analgesics daily (odds ratio [95%] confidence interval: 1.86 [1.25-2.77]) 6 to 12 months postinjury.

CONCLUSION

The variation in opioid prescription after traumatic injury is more affected by system and provider level rather than clinical or patient-related factors, and opioid prescribing correlates independently with long-term chronic pain and continued analgesic use postinjury. Efforts to decrease opioid use should prioritize standardizing prescription practices after traumatic injury.

Psychosocial Predictors of Chronic Pain 12 Months After Surgical Fixation for Lower Extremity Fracture: A Prospective Study

OBJECTIVE

Pain is a common outcome after lower extremity fracture (LEF) requiring surgical fixation. Although psychosocial characteristics have meaningful associations with adverse outcomes, no studies have evaluated how psychosocial characteristics throughout recovery are associated with pain outcomes. The primary purpose of this study was to determine whether psychosocial characteristics are early risk factors for pain outcomes in patients following LEF who have no history of chronic pain.

METHODS

Participants, 122 patients with a LEF, consented to this single-center, prospective cohort study. Measurements of depression, pain self-efficacy, pain catastrophizing, and fear of movement were completed at 1 week, 6 weeks, 3 months, 6 months, and 12 months after LEF. Chronic pain development and pain intensity were assessed at 12 months. Univariate analyses assessing the difference between means and corresponding effect sizes were evaluated between those individuals with and without chronic pain at 12 months. Separate logistic and linear regression models using psychosocial scores at each time point were used to determine the association with the development of chronic pain and pain intensity, respectively.

RESULTS

Of 114 patients (93.4%) who completed the study, 51 (45%) reported chronic pain at 12 months. In the univariate analysis, all psychosocial variables at 6 weeks, 3 months, 6 months, and 12 months were significantly different between those with and those without chronic pain at 12 months (Cohen d range = 0.84 to 1.65). In the multivariate regression models, all psychosocial variables at 6 weeks, 3 months, and 6 months were associated with chronic pain development (odds ratio range = 1.04 to 1.22) and pain intensity (β range = .05 to .14) at 12 months.

CONCLUSION

Psychosocial scores as early as 6 weeks after surgery are associated with pain outcomes 12 months after LEF.

IMPACT

Physical therapists should consider adding psychosocial screening throughout recovery after LEF to identify patients at increased risk for long-term pain outcomes.

Patient Mental Health and Well-being: Its Impact on Orthopaedic Trauma Outcomes

A patient's mental health can have a significant impact on their orthopaedic trauma outcome. It is important for orthopaedic surgeons to identify patients at risk for a poor outcome based on their mental health, to include the presence of post-traumatic stress disorder, depression, and anxiety, among others. Although some behaviors such as catastrophizing have been associated with worse outcomes, others, such as possessing greater self-efficacy have been associated with improved outcomes. Because of the high prevalence of mental health conditions that can have a detrimental effect on outcome, screening should be routinely conducted and at-risk patients referred to appropriate resources in an effort to optimize outcomes.

Resources for Patient Mental Health and Well-being after Orthopaedic Trauma

Orthopaedic trauma is an unanticipated life-altering experience for patients. Additionally, the prevalence of psychiatric disorders has been found to be higher in patients with trauma than in the general adult population. Symptoms of depression, anxiety, or posttraumatic stress disorder have been reported in up to 56% of patients throughout their postoperative course. Furthermore, symptoms of any one of these illnesses have been consistently associated with worse patient outcomes after treatment of traumatic orthopaedic injuries. This includes increased levels of pain and disability, postoperative complications, and, in some cases, higher rates of hospital readmission. For most patients with trauma, focus is placed on physical therapy and rehabilitation in the acute postoperative setting to help patients regain function and strength; however, more recent studies have demonstrated equal importance of the social and psychological factors involved with trauma and their impact on outcomes. Therefore, it is essential for orthopaedic surgeons and other members of the care team to be adept in the screening and treatment of psychiatric disorders. For patients struggling with these conditions, several treatment resources exist, which can be used both during their admission and after discharge. Thus, earlier recognition and intervention with appropriate treatment and referrals should be emphasized to improve outcomes. This review discusses the social and psychological impacts of orthopaedic trauma on patients' mental health and well-being and outlines numerous resources available to patients as they recover from their injuries.

Association between spine injury and opioid misuse in a prospective cohort of Level I trauma patients

Objective

To explore patient and treatment factors explaining the association between spine injury and opioid misuse.

Design

Prospective cohort study.

Setting

Level I trauma center in a Midwestern city.

Participants

English speaking patients aged 18 to 75 on Trauma and Orthopedic Surgical Services receiving opioids during hospitalization and prescribed at discharge.

Exposure

Spine injury on the Abbreviated Injury Scale.

Main outcome measures

Opioid misuse was defined by using opioids: in a larger dose, more often, or longer than prescribed; via a non-prescribed route; from someone other than a prescriber; and/or use of heroin or opium. Exploratory factor groups included demographic, psychiatric, pain, and treatment factors. Multivariable logistic regression estimated the association between spine injury and opioid misuse when adjusting for each factor group.

Results

Two hundred eighty-five eligible participants consented of which 258 had baseline injury location data and 224 had follow up opioid misuse data. Most participants were male (67.8%), white (85.3%) and on average 43.1 years old. One-quarter had a spine injury (25.2%). Of those completing follow-up measures, 14 (6.3%) developed misuse. Treatment factors (injury severity, intubation, and hospital length of stay) were significantly associated with spine injury. Spine injury significantly predicted opioid misuse [odds ratio [OR] 3.20, 95% confidence interval [CI] (1.05, 9.78)]. In multivariable models, adjusting for treatment factors attenuated the association between spine injury and opioid misuse, primarily explained by length of stay.

Conclusion

Spine injury exhibits a complex association with opioid misuse that predominantly operates through treatment factors. Spine injury patients may represent a subpopulation requiring early intervention to prevent opioid misuse.

Opioid administration in the prehospital setting for patients sustaining traumatic injuries: An evaluation of national emergency medical services data

INTRODUCTION

Despite concerns about long-term dependence, opioids remain the mainstay of treatment for acute pain from traumatic injuries. Additionally, early pain management has been associated with improved long-term outcomes in injured patients. We sought to identify the patterns of prehospital pain management across the United States.

METHODS

We used 2019 national emergency medical services (EMS) data to identify the use of pain management for acutely injured patients. Opioid specific dosing was calculated in morphine milligram equivalents (MME). The effects of opioids as well as adverse events were identified through objective patient data and structured provider documentation.

RESULTS

We identified a total of 3,831,768 injured patients, 85% of whom were treated by an advanced life support (ALS) unit. There were 269,281 (7.0%) patients treated with opioids, including a small number of patients intubated by EMS (n = 1537; 0.6%). The median opioid dose was 10 MME [IQR 5-10] and fentanyl was the most commonly used opioid (88.2%). Patients treated with opioids had higher initial pain scores documented by EMS than those not receiving opioids (median: 9 vs 4, p<0.001), and had a median reduction in pain score of 3 points (IQR 1-5) based on the final prehospital pain score. Adverse events associated with opioid administration, including episodes of altered mental status (n = 453; 0.2%) and respiratory compromise (n = 252; 0.1%), were rare. For patients with severe pain (≥8/10), 27.3% of patients with major injuries (ISS ≥15) were treated with opioids, compared with 24.8% of those with moderate injuries (ISS 9-14), and 21.4% of those with minor (ISS 1-8) injuries (p<0.001).

CONCLUSION

The use of opioids in the prehospital setting significantly reduced pain among injured patients with few adverse events. Despite its efficacy and safety, the majority of patients with major injuries and severe pain do not receive opioid analgesia in the prehospital setting.

Psychological resilience as a predictor of opioid consumption after orthopaedic trauma

INTRODUCTION

Psychological distress after orthopaedic trauma negatively affects patient outcomes. Resilience may mediate distress and therefore be associated with post-operative outcomes, including opioid use. The purpose of this study is to evaluate the relationship between resilience and post-operative opioid demand with the hypothesis that low levels of resilience are associated with increased opioid consumption.

MATERIALS AND METHODS

Patients age 18 - 65 at a single, tertiary care level 1 trauma center who underwent operative treatment of pelvic and/ or extremity fractures between 3/2017 - 6/2018 were contacted by phone to complete the OSPRO-YF, a ten-item screening tool that assesses psychological distress. Participants were screened for scores in the worst quartile (i.e., yellow flag) for resilience. Baseline patient and injury characteristics and opioid demand were compared between patients with and without positive yellow flags for resilience using Wilcoxon rank-sum for continuous variables and Fisher exact test for categorical variables.

RESULTS

A total of 117 patients were surveyed. Patients with positive yellow flag screening scores for resilience had significantly higher opioid demand, number of opioid prescriptions filled, and were more likely to refill prescriptions long-term (3-months post-discharge to one-year post-discharge). Patients with a positive yellow flag for resilience had a significantly higher number of opioid prescriptions filled in the cumulative (one-month pre-op to one-year post-discharge) time period.

DISCUSSION/ CONCLUSION

Lower long-term resilience scores were associated with higher postoperative opioid consumption, fill and refill rates. These results suggest low resilience may be a risk factor for increased long-term opioid consumption following surgical treatment for orthopaedic trauma.

Clinical outcomes following major trauma for patients with a diagnosis of depression: a large UK database analysis

Background

More than a quarter of the UK population are affected by depression during their lifetime. For major trauma patients, postinjury depression can result in poorer long-term outcomes, but there is limited evidence regarding outcomes for patients with pre-existing depression. This study investigated the relationship between a diagnosis of depression prior to hospital admission and clinical outcomes after major trauma.

Methods

Trauma patients at a UK major trauma center were identified during a 6.5-year period using the Trauma Audit and Research Network database. Patients with Injury Severity Score >15 who did not die in the emergency department (ED) were included. Logistic regression models were used to compare in-hospital mortality (excluding ED), requirement for surgery, and length of stay (LOS) between those with depression and those without.

Results

There were 4602 patients included in the study and 6.45% had a diagnosis of depression. Depression was associated with a significant reduction in mortality (OR 0.54, 95% CI 0.30 to 0.91; p=0.026). However, patients with depression were more likely to have longer LOS (OR 124, 95% CI 8.5 to 1831; p<0.001) and intensive care unit LOS (OR 9.69, 95% CI 3.14 to 29.9; p<0.001). Patients with depression were also more likely to undergo surgery (OR 1.36, 95% CI 1.06 to 1.75; p=0.016).

Discussion

A pre-existing diagnosis of depression has complex association with clinical outcomes after major trauma, with reduced mortality but longer LOS and higher likelihood of surgical intervention. Further prospective investigations are warranted to inform optimal management strategies for major trauma patients with pre-existing depression.

Level of evidence

III.

Changing Pain Management Strategy from Opioid-Centric towards Improve Postoperative Cognitive Dysfunction with Dexmedetomidine

OBJECTIVE

This study was aimed to investigate the effectiveness of dexmedetomidine (DEX) on improving the level of pain and disability to find out the possible correlation between psychological factors with pain management satisfaction and physical function in patients with femoral neck fractures.

METHODS

One hundred twenty-four adult patients with stable femoral neck fractures (type I and II, Garden classification) who underwent internal fixation, were prospectively enrolled including 62 patients in the DEX group and 62 patients in the control group. The magnitude of disability using Harris Hip Score, Postoperative Cognitive Dysfunction (POCD) using Mini-Mental State Examination (MMSE score), Quality of Recovery (QoR-40), pain-related anxiety (PASS-20), pain management and pain catastrophizing scale (PCS) were recorded on the first and second day after surgery.

RESULTS

The DEX group on the first and second days after surgery exhibited higher quality of recovery scores, greater satisfaction with pain management, low disability scores, less catastrophic thinking, lower pain anxiety, greater mini mental state examination scores and less opioid intake and the differences were statistically significant compared with the control group (P<0.001). Emergence agitation and incidence of POCD were significantly less in the DEX group (P<0.001). Decreased disability was associated with less catastrophic thinking and lower pain anxiety, but not associated with more opioid intake (P<0.001). Higher QoR-40 scores had a negative correlation with more catastrophic thinking and more opioid intake (P<0.001). Greater satisfaction with pain management was correlated with less catastrophic thinking and less opioid intake (P<0.001).

CONCLUSION

Using DEX as an adjunct to anesthesia could significantly improve postoperative cognitive dysfunction and the quality of recovery and these improvements were accompanied by decrease in pain, emergence agitation, and opioid consumption by DEX administration. Since pain relief and decreased disability were not associated with prescribing greater amounts of opioid intake in the patients, improving psychological factors, including reducing catastrophic thinking or self-efficacy about pain, could be a more effective strategy to reduce pain and disability, meanwhile reducing opioid prescription in the patients. Our findings showed that DEX administration is safe sedation with anti-inflammatory, analgesic and antiemetic effects and it could help change pain management strategy from opioid-centric towards improved postoperative cognitive dysfunction.

Self-efficacy corresponds to wrist function after combined plating of distal radius fractures

STUDY DESIGN

A prospective cohort single-center study.

INTRODUCTION

Self-efficacy (SE) refers to beliefs in ones capabilities to organize and execute the courses of action required to produce given goals. High SE is an important factor for recovery from injury/illness; people who believe in their capability will more likely reach a good outcome.

PURPOSE OF THE STUDY

The aim of this study was to examine if SE has an effect to physical functioning, pain and patient-rated wrist function three months postoperatively in patients undergoing plating due to a distal radius fracture.

METHODS

Sixty-seven patients undergoing plating for a distal radius fracture rated SE at the first appointment with the physiotherapist. At the three-month follow-up, the following assessments were administered: Patient-Rated Wrist Evaluation (PRWE), pain-scores, hand grip strength, and range of motion.

RESULTS

The group with a high SE showed significantly better range of motion for flexion (P = .046) and supination (P = .045), hand grip strength (P = .001) and PRWE scores (P = .04). The NRS pain during activity was lower, although not significantly lower (P = .09). Using Spearman's rank correlation coefficient, there was a moderate correlation between SE and pain during activity, wrist flexion, and PRWE score.

DISCUSSION

SE corresponds to wrist function after combined plating of distal radius fractures.

CONCLUSION

Measurement of SE could possibly be useful to identify patients in special need of support during the postoperative rehabilitation.

Relationship between pain intensity, pain catastrophizing, and self-efficacy in patients with frozen shoulder: a cross-sectional study

Background

Pain catastrophizing and self-efficacy are useful for predicting pain; these are associated with pain intensity and facilitate evaluation of psychological factors. However, it remains unclear whether the effects are direct or indirect in patients with frozen shoulder; the impact on each variable has also not been clarified. Thus, this study aimed to examine the structural relationship between pain catastrophizing, self-efficacy, and pain intensity in patients with frozen shoulder.

Methods

Participants who were diagnosed with frozen shoulder between January 2016 and March 2017 were recruited from a single orthopedic clinic. Patients aged 18 years or older, who had been symptomatic for < 1 year and reported localized pain in one shoulder, experienced night pain, and had restricted active and passive shoulder motions were included. Pain intensity (Numerical Rating Scale (NRS)), pain catastrophizing (Pain Catastrophizing Scale (PCS)), and self-efficacy (Pain Self-Efficacy Questionnaire (PSEQ)) were measured at the first examination, and the relationship was examined using the Bayesian estimation method. The model was modified repeatedly based on the posterior prediction p value, deviance information criterion (DIC), and Bayesian information criterion (BIC); the model with the highest explanatory power was adopted as the final model.

Results

Ninety-three patients diagnosed with frozen shoulder were included in this study. On path analysis, the model in which pain intensity affected psychological factors had the most explanation. The convergence index potential scale reduction was below 1.1, and the convergence of the estimate was confirmed. The posterior prediction p value was 0.25, DIC = 1328.705, and BIC = 1356.872; the validity of the fit of the model was confirmed. The path coefficients from the NRS to the PSEQ, from the NRS to the PCS, and from the PSEQ to the PCS scores were − 0.232 (95% confidence interval (CI), − 0.406 to − 0.033), 0.259 (95% CI, 0.083–0.419), and − 0.504 (95% CI, − 0.646 to − 0.334), respectively; these values were statistically significant (p < 0.05).

Conclusion

Our results show that pain intensity increases the risk of chronic pain including pain catastrophizing and self-efficacy and that pain catastrophizing increases by decreasing self-efficacy in patients with frozen shoulder.

Discharge from the trauma centre: exposure to opioids, unmet information needs and lack of follow up-a qualitative study among physical trauma survivors

Background

Physical trauma is associated with mortality, long-term pain and morbidity. Effective pain management is fundamental in trauma care and opioids are indispensable for treating acute pain; however, the use and misuse of prescribed opioids is an escalating problem. Despite this, few studies have been directed towards trauma patients in an early phase of rehabilitation with focusing on experiences and perspectives of health and recovery including pain and persistent use of prescribed opioids with abuse potential. To explore pre- and post-discharge trauma care experiences, including exposure to opioids, physical trauma survivors were recruited from a major trauma centre in Norway that provides the highest level of surgical trauma care.

Method

Qualitative exploratory study. Individual semi-structured interviews were conducted among 13 trauma patients with orthopedic injuries, known to be associated with severe pain, six weeks post-discharge. The interviews were recorded, transcribed verbatim, and thematically analyzed with an interdisciplinary approach.

Results

The overarching theme was that discharge from the trauma centre and the period that immediately followed were associated with feelings of insecurity. The three main themes that were identified as contributing to this was (a) unmet information needs about the injury, (b) exposure to opioids, and (c) lack of follow-up after discharge from the hospital. Participants experienced to be discharged with prescribed opioids, but without information about their addictive properties or tapering plans. This, and lack of attention to mental health and psychological impact of trauma, gave rise to unmet treatment needs of pain management and mental health problems during hospitalization and following discharge.

Conclusion

The findings from this study suggest that in addition to delivery of high-quality biomedical trauma care, health professionals should direct more attention to psychosocial health and safe pain management, including post-discharge opioid tapering and individually tailored follow-up plans for physical trauma survivors.

Can educational videos reduce opioid consumption in trauma inpatients? A cluster-randomized pilot study

BACKGROUND

Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation.

METHODS

We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed.

RESULTS

In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos.

CONCLUSION

Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Exploring what is important to patients with regards to quality of life after experiencing a lower limb reconstructive procedure: a qualitative evidence synthesis

BACKGROUND

Patient reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction surgery on patients' quality of life (QOL). Existing measures have not been developed to specifically capture patient experiences amongst adults with lower limb conditions that require reconstruction surgery. This review aimed to synthesise qualitative evidence to identify what is important to patients requiring, undergoing, or following reconstructive surgery for lower limb conditions.

METHODS

MEDLINE, Embase, PsychINFO and Cinahl were searched from inception until November 2020. Studies were included if they employed qualitative research methods, involved patients requiring, undergoing or following lower limb reconstruction and explored patients' experiences of care, treatment, recovery and QOL. Mixed methods studies that did not separately report qualitative findings, mixed population studies that were not separately reported and studies in languages other than English were excluded. Included studies were analysed using thematic synthesis. The Critical Appraisal Skills Programme qualitative studies checklist was used to undertake quality assessment.

RESULTS

Nine studies met the inclusion criteria. The thematic synthesis identified two overarching themes: (1) areas of living key to QOL for lower limb reconstruction patients and (2) moving towards a new normal. The way in which lower limb reconstruction affects an individual's QOL and their recovery is complex and is influenced by a range of inter-related factors, which will affect patients to varying degrees depending on their individual circumstances. We identified these factors as: pain, daily functioning and lifestyle, identity, income, emotional wellbeing, support, the ability to adapt and adjust and the ability to move forwards.

CONCLUSIONS

The way patients' QOL is affected after a lower limb reconstruction is complex, may change over time and is strongly linked to their recovery. These findings will aid us in developing a conceptual framework which identifies the outcomes important to patients and those that should be included in a PROM. Further research is then required to establish whether the range of factors we identified are captured by existing PROMs. Depending on the outcome of this work, a new PROM for patients following lower limb reconstruction may be required.

The Effect of Psychological Interventions on the Prevention of Chronic Pain in Adults: A Systematic Review and Meta-analysis

OBJECTIVE

Up to 50% of patients develop high-impact chronic pain after an acute care experience and many psychological variables have been identified in this process. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the effect of psychological interventions within 3 months after pain onset.

METHODS

We searched databases for articles published from databases inceptions until July 2019. We used standardized mean differences with 95% confidence intervals to assess treatment effect.

RESULTS

In all, 18 trials were found eligible; 11 of which were included in the meta-analyses. Trials were mainly performed in back pain patients in the middle to late adulthood. Regarding pain intensity, the effect of psychological interventions compared with standard treatments was nonsignificant at 3, 6, and 12 months. We found a moderate significant effect size in favor of psychological interventions compared with standard treatments with regard to disability at 12 months and a small significant effect with regard to coping with pain at 3 months when compared with information alone. Most of meta-analysis findings were associated with a low level of evidence.

DISCUSSION

This systematic review and meta-analysis showed no significant effect of psychological interventions on pain intensity. A positive and significant trend related to these interventions was shown on disability and coping with pain, when compared with standard treatment and information, respectively. However, these findings must be interpreted with caution considering the limited sample of trials. More rigorous randomized controlled trials performed in patients with a high-risk psychological profile are required to elucidate the efficacy of psychological interventions in preventing chronic pain.

Trends in opioid prescription for craniomaxillofacial trauma in the United States: An 11-year retrospective study of emergency room and office visits

BACKGROUND

Facial trauma is associated with significant long-term morbidity and pain. These patients are routinely prescribed opioid medication and are at risk for opioid dependence. Rates and trends in opioid prescription in the ambulatory setting for management of craniofacial trauma are unknown.

METHODS

The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data were analyzed from 2006 to 2016. Using International Classification of Diseases codes, 7,997,454 visits for craniomaxillofacial trauma were identified. Trends in opioid and nonopioid prescriptions were studied, with variables of interest including demographics, geographic region, expected source of payment, and injury location.

RESULTS

Over the study period, trends in both opioid and nonopioid prescriptions remained stable, with about 13.4% of all visits receiving opioid prescriptions. Patients aged 18 to 44 (P < .001) and lower face trauma (P = .047) were associated with increased rates, while Medicare and charity payers (P < .001) were associated with lower rates of opioid prescriptions. There was no significant difference in prescription rates across geographical regions, by ethnicity, or sex.

CONCLUSION

Opioid medication forms the cornerstone for ambulatory management of craniofacial trauma. Despite increased awareness and emphasis on multimodal pain management, opioid prescription trends have remained relatively stable over time.

The Psychological Effects of Musculoskeletal Trauma

Musculoskeletal injuries comprise a large percentage of hospital admissions for adults and often contribute to persistent daily pain as an illness; opioid dependence; disability; and complaints of increased depression, anxiety, and symptoms of post-traumatic stress disorder. The prevalence of depression and post-traumatic stress disorder after orthopaedic trauma has been found to be considerably greater than the general adult cohort. Soon after sustaining a fracture, psychological factors can predict pain and disability many months after injury, even after controlling for injury severity. Thus, early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health. Recent literature has identified clinically actionable subgroups within the orthopaedic trauma cohort that are at psychological risk after an injury. Improving positive factors such as resilience, social support, and self-efficacy via validated interventions such as Cognitive-Behavioral Therapy, mindfulness training, and other types of mindset training has helped people return to their daily routine. Raising awareness of the psychological effects of trauma among the orthopaedic community could improve post-treatment planning, increase referrals to appropriate nonmedical professionals, and implement earlier effective interventions.

Validation of the Persian version of the Compassionate Care Assessment Tool

OBJECTIVES

The present study aimed to translate and determine the psychometric properties of the Persian version of the Compassionate Care Assessment Tool (CCAT) ©.

METHODS

The study was carried out to translate and validate of the CCAT©. After securing permission from the designer of the tool and translating it, the psychometric properties were determined through examining face validity, construct validity, internal consistency, and test/retest reliability. With regard to construct validity, confirmatory factor analysis was used so that 300 patients in internal and surgery wards were selected by a simple random sampling method from three hospitals. Data were analyzed using SPSS (v.24.0) and LISREL statistical software version 8.8.

RESULTS

The results of the confirmatory factor analysis supported the validity and reliability of the Persian version of the CCAT© and its four factors. The reliability of the tool and internal consistency were confirmed through test/retest method with two weeks' interval. At the two areas of importance and provision of compassionate care, Cronbach's α coefficient equaled to 0.918 and 0.933 and intraclass consistency equaled to 0.848 and 0.907 respectively.

CONCLUSION

The results showed that the Persian version of the CCAT© was adequately valid and reliable for Iranian patients. Given the acceptable psychometric parameters of the tool, using it in future studies to measure importance and provision of compassionate nursing care to Iranian patients at internal and surgery wards is recommended.

A Multidisciplinary Approach to Improve Pain Management and Satisfaction in a Trauma Population

An adult trauma center identified pain management as a potential area for improvement. Pain management is at the height of discussion in medical centers across the United States. The Hospital Consumer Assessment of Healthcare Provider and System (HCAHPS) scores relating to pain management were consistently low (<5th percentile). This project was designed to use a collaborative and systematic approach to pain management to improve HCAHPS pain management scores. This is an evaluation of a quality improvement project using a before-and-after design with historical control. Using HCAHPS data to evaluate patients' pain management perceptions, an integrative three-pronged approach was developed and implemented: (1) development of a trauma nurse leadership program, (2) collaboration with pain management providers, and (3) modifications made to the trauma admission order set. Trauma nurse leaders educated patients and families regarding pain management goals and expectations utilizing a standardized script. HCAHPS survey data obtained before and after the intervention showed a significant improvement in patient satisfaction. HCAHPS scores on the three pain questions prior to intervention in Quarters 2 and 3 (Q2-3) 2017 had a mean of less than the 5th percentile. After intervention, HCAHPS scores on the three pain questions improved to a mean of more than the 60th percentile on Q4 2018. Implementation of a pain management strategy involving a three-pronged approach of a dedicated trauma nurse leadership program, collaboration with a pain management team, and evaluation and modification of a trauma admission order set was associated with an improvement in communication about pain with the trauma patients and HCAHPS pain satisfaction scores.

Reliability and Validity Evidence of the STarT-Lower Extremity Screening Tool for Patients With Lower Extremity Fracture: A Prospective Study

OBJECTIVES

To determine whether a modified version of the STarT Back Screening Tool in its current structure has adequate properties for use in patients with lower extremity fracture.

DESIGN

Single-center, prospective study.

SETTING

Level I trauma center.

PARTICIPANTS

Patients with lower extremity fracture without a history of chronic pain (N=114), with 93% follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Six weeks after surgical fixation, individuals completed the Subgroups for Targeted Treatment of Lower Extremity Screening Tool (STarT-LE). A subsample completed the STarT-LE again 1 week later. The following questionnaires were completed at 6 weeks and 6 months: Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Brief Pain Inventory pain intensity subscale, and PROMIS Depression and Pain Interference computer adaptive testing modules. Reliability was evaluated using intraclass correlation coefficients (ICC) and Cronbach's alpha (α). Convergent validity evidence was measured concurrently using the Spearman ρ correlation between the 6-week STarT-LE and established questionnaires. Predictive validity evidence was evaluated by area under the curve analysis (AUC) using the 6-week STarT-LE total and psychosocial scores and 6-month criterion physical and psychosocial reference standards.

RESULTS

The STarT-LE has good test-retest reliability (ICC, 0.85; 95% confidence interval, 0.78-0.91) and acceptable internal consistency (α=0.74). The convergent validity evidence was fair to moderate (ρ, 0.53-0.68; P<.001) and the predictive validity evidence was acceptable to excellent (AUC, 0.73-0.84).

CONCLUSIONS

The STarT-LE has adequate properties for use in patients with lower extremity fracture. Future larger scale studies are needed to validate risk cutoffs.

Successful engagement in buprenorphine treatment among hospitalized patients with opioid use disorder and trauma

BACKGROUND

The opioid epidemic continues to cause significant morbidity and mortality. Although there are effective medications for opioid use disorder (OUD), a minority of patients receive these treatments. OUD is common among patients hospitalized for traumatic injury and hospitalization could be an opportunity to initiate medications and link to ongoing buprenorphine care.

METHODS

This retrospective cohort study based on electronic health record review included patients who were: (1) hospitalized between January 1, 2018 and June 30, 2019, (2) age ≥18 years, (3) seen by an Addiction Medicine Consult Service, and (4) initiated on buprenorphine with plans for continuation post-discharge. Descriptive statistics identified differences between trauma and non-trauma groups and regression analysis identified predictors of 30 day buprenorphine follow up.

RESULTS

Of 197 eligible patients, 60 (30.5 %) were hospitalized for traumatic injuries. Compared to non-trauma patients, trauma patients were younger, more likely to be employed, more likely to report using cannabis and tobacco, less likely to have recently injected drugs, and hospitalized longer. Among patients with follow-up data available (n = 147), 63.2 % of trauma patients were seen within 30 days, compared to 48.2 % of non-trauma patients (p = 0.16). There were no significant differences between the two groups with regards to urine drug test results or acute care utilization in the follow-up period.

CONCLUSIONS

Among hospitalized patients with OUD who initiate buprenorphine, those who were hospitalized for trauma were at least as likely to link to out-patient treatment. Trauma admissions represent an important opportunity for diagnosing and linking patients with OUD to buprenorphine treatment.

Trauma patients returning to the emergency department after discharge

BACKGROUND

While readmission rates of trauma patients are well described, little has been reported on rates of re-presentation to the emergency department (ED) after discharge. This study aimed to determine rates and contributing factors of re-presentation of trauma patients to the ED.

METHODS

One-year retrospective analysis of discharged adult trauma patients at a county-funded safety-net level one trauma center.

RESULTS

Of 1416 trauma patients, 195 (13.8%) re-presented to the ED within 30 days. Of those that re-presented, 47 (24.1%) were re-admitted (3.3% overall). The most common reasons for re-presentation were pain control and wound complications. Patients with Medicare (AOR 2.6, 95% CI 1.3 to 5.2) or other government insurance (AOR 2.5, 95% CI 1.6 to 4.1) were more likely to re-present than patients with private insurance.

CONCLUSION

A considerable number of trauma patients re-presented to the ED after discharge for reasons that did not require hospitalization. Discharge planning for certain vulnerable groups should emphasize wound care, pain control and scheduled follow-up to decrease the reliance on the ED.

Reason to doubt the ICHD-3 7-day inclusion criterion for mild TBI-related posttraumatic headache: A nested cohort study

Background

Posttraumatic headache is difficult to define and there is debate about the specificity of the 7-day headache onset criterion in the current definition. There is limited evidence available to guide decision making about this criterion.

Method

A nested cohort study of 193 treatment-seeking veterans who met criteria for persistent headache attributed to mild traumatic injury to the head, including some veterans with delayed headache onset up to 90 days post-injury, was undertaken. Survival analysis examined the proportion of participants reporting headache over time and differences in these proportions based on sex, headache phenotype, and mechanism of injury.

Result

127 participants (66%; 95% CI: 59–72%) reported headache onset within 7 days of head injury and 65 (34%) reported headache onset between 8 days and 3 months after head injury. Fourteen percent of participants reported pre-existing migraine before head injury, and there was no difference in the proportion of veterans with pre-existing migraine based on headache onset. Headache onset times were not associated with sex, headache phenotype, or mechanism of injury. There were no significant differences in proportion of veterans with headache onset within 7 days of head injury based on headache phenotype (70% migraine onset within 7 days, 70% tension-type headache within 7 days, 56% cluster headache within 7 days; p ≥ .364). Similar findings were observed for head injury (64% blast, 60% blunt; p = .973). There were no significant differences observed between headache onset groups for psychiatric symptoms (Posttraumatic Stress Disorder Checklist for DSM-5 = 1.3, 95% CI = −27.5, 30.1; Patient Health Questionnaire-9 Item = 3.5, 95% CI = −6.3, 3.7; Generalized Anxiety Disorder Screener = 6.5, 95% CI = −2.7, 15.6).

Conclusions

Although most of the sample reported headache onset within 7 days of head injury, one-third experienced an onset outside of the diagnostic range. Additionally, veterans with headache onset within 7 days of head injury were not meaningfully different from those with later onset based on sex, headache phenotype, or mechanism of head injury. The ICHD-3 diagnostic criteria for 7-day headache onset should be expanded to 3 months.

ClinicalTrials.gov Identifier

NCT02419131

Multimodal Analgesia and Decreased Opioid Use in Adult Trauma Patients

BACKGROUND

There is an opioid epidemic in the United States. With the increased concern of over-prescribing opioids, physicians are seeking alternative pain management strategies. The purpose of this study is to review the impact of instituting a multimodal analgesia (MMA) guideline on decreasing opioid use in trauma patients at a Level 1 trauma center.

METHODS

In 2017, an MMA guideline was developed and included anti-inflammatories, muscle relaxants, neuropathic agents, and local analgesics in addition to opioids. Staff were educated and the guideline was implemented. A retrospective review of medications prescribed to patients admitted from 2016 through 2018 was performed. Patients admitted in 2016 served as the control group (before MMA). In 2018, all patients received multimodal pain therapy as standard practice, and served as the comparison group.

RESULTS

A total of 10 340 patients were admitted to the trauma service from 2016 through 2018. There were 3013 and 3249 patients for review in 2016 and 2018, respectively. Total morphine milligram equivalents were 2 402 329 and 1 975 935 in 2016 and 2018, respectively, a 17.7% decrease (P < .001). Concurrently, there was a statistically significant increase in the use of multimodal pain medications. A secondary endpoint was studied to evaluate for changes in acute kidney injury; there was not a statistically significant increase (0.56% versus 0.68%, P = .55).

DISCUSSION

Implementation of an MMA guideline significantly reduced opioid use in trauma patients. The use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.

Identifying Factors Most Important to Lower Extremity Trauma Patients: Key Concepts from the Development of a Patient-Reported Outcome Instrument for Lower Extremity Trauma, The LIMB-Q

BACKGROUND

Severe lower extremity injuries are challenging to treat. The aspects of limb salvage and amputation most important to patients are not well-defined. This study's aim is to develop a conceptual framework for a patient-reported outcome instrument for lower extremity trauma patients, by defining issues and concepts most important to this patient population.

METHODS

This is an interpretative description of transcripts collected from semistructured qualitative interviews at a single institution. High-energy lower extremity trauma patients were recruited by means of purposeful sampling to maximize variability. Thirty-three participant interviews were needed to reach content saturation. These participants were aged 19 to 79 years; 21 were men (63.6 percent); participation was after reconstruction [n= 15 (45.5 percent)], after amputation [n = 11 (33.3 percent)], or after amputation after failed reconstruction [n = 7 (21.2 percent)]. Interviews were recorded, transcribed, and coded line-by-line. Concepts were labeled with major and minor themes and refined through a process of constant comparison. Analysis led to the development of a conceptual framework and item pool to inform the development of a patient-reported outcome measure.

RESULTS

In total, 2430 unique codes were identified and used to generate the conceptual framework covering 10 major themes: appearance, environment, finances, physical, process of care, prosthesis, psychological, sexual, social, and treatment.

CONCLUSIONS

This study establishes a comprehensive set of concepts, identifying what is most important to severe lower extremity trauma patients. These findings can be used to inform and focus research and clinical care, and provides the framework to develop a lower extremity trauma-specific patient-reported outcome instrument: the LIMB-Q.

Evidence-Based Strategies for the Prevention of Chronic Post-Intensive Care and Acute Care-Related Pain

Chronic pain is prevalent in intensive care survivors and in patients who require acute care treatments. Many adverse consequences have been associated with chronic post-intensive care and acute care-related pain. Hence, interest in interventions to prevent these pain disorders has grown. To improve the understanding of the mechanisms of action of these interventions and their potential impacts, this article outlines the pathophysiology involved in the transition from acute to chronic pain, the epidemiology and consequences of chronic post-intensive care and acute care- related pain, and risk factors for the development of chronic pain. Pharmacological, nonpharmacological, and multimodal preventive interventions specific to the targeted populations and their levels of evidence are presented. Nursing implications for preventing chronic pain in patients receiving critical and acute care are also discussed.

Moderate to severe acute pain disturbs motor cortex intracortical inhibition and facilitation in orthopedic trauma patients: A TMS study

OBJECTIVE

Primary motor (M1) cortical excitability alterations are involved in the development and maintenance of chronic pain. Less is known about M1-cortical excitability implications in the acute phase of an orthopedic trauma. This study aims to assess acute M1-cortical excitability in patients with an isolated upper limb fracture (IULF) in relation to pain intensity.

METHODS

Eighty-four (56 IULF patients <14 days post-trauma and 28 healthy controls). IULF patients were divided into two subgroups according to pain intensity (mild versus moderate to severe pain). A single transcranial magnetic stimulation (TMS) session was performed over M1 to compare groups on resting motor threshold (rMT), short-intracortical inhibition (SICI), intracortical facilitation (ICF), and long-interval cortical inhibition (LICI).

RESULTS

Reduced SICI and ICF were found in IULF patients with moderate to severe pain, whereas mild pain was not associated with M1 alterations. Age, sex, and time since the accident had no influence on TMS measures.

DISCUSSION

These findings show altered M1 in the context of acute moderate to severe pain, suggesting early signs of altered GABAergic inhibitory and glutamatergic facilitatory activities.

Risk factors and outcomes of chronic opioid use following trauma

Background

The growing problem of opioid misuse has become a serious crisis in many countries. The role of trauma as a gateway to opioid use is currently not determined. The study was undertaken to assess whether traumatic injury might be associated with chronic opioid use and accompanying increased long-term mortality.

Methods

Injured patients and controls from Sweden were matched for age, sex and municipality. After linkage to Swedish health registers, opioid consumption was assessed before and after trauma. Among injured patients, logistic regression was used to investigate factors associated with chronic opioid use, assessed by at least one written and dispensed prescription in the second quarter after trauma. Cox regression was employed to study excess risk of mortality. In addition, causes of death for postinjury opioid users were explored.

Results

Some 13 309 injured patients and 70 621 controls were analysed. Exposure to trauma was independently associated with chronic opioid use (odds ratio 3·28, 95 per cent c.i. 3·02 to 3·55); this use was associated with age, low level of education, somatic co-morbidity, psychiatric co-morbidity, pretrauma opioid use and severe injury. The adjusted hazard ratio for death from any cause 6–18 months after trauma for chronic opioid users was 1·82 (95 per cent c.i. 1·34 to 2·48). Findings were similar in a subset of injured patients with no pretrauma opioid exposure.

Conclusion

Traumatic injury was associated with chronic opioid use. These patients have an excess risk of death in the 6–18 months after trauma.

Implementing recovery resources in trauma care: impact and implications

Objectives:

To identify resources that patients perceive as helpful to their recovery and to characterize the impact of the Trauma Survivor Network (TSN), a program committed to enhancing recovery through education and engagement.

Design:

Prospective cohort study.

Setting:

Level 1 trauma center.

Patients/Participants:

Four hundred eighty-five patients with musculoskeletal injuries. Two hundred eleven were exposed to TSN resources (Group 1). One hundred thirty-five patients were treated during the same period with no exposure (Group 2, control). One hundred thirty-nine patients were treated 1 to 3 months prior to TSN implementation (Group 3, control).

Intervention:

TSN resources including educational materials, family classes, peer survivor visits, coaching, online services, and support groups.

Main outcome measure:

A survey to assess hospital experience and perceptions about recovery.

Results:

On a Likert scale from 0 to 5, patients were highly satisfied (mean 4.24), with no differences based on TSN exposure. Patients exposed to TSN programming reported greater perceived likelihood of recovery: mean 3.73 vs 3.41 vs 3.38, Group 1 vs Group 2 vs Group 3 (P = .05) and regarding return to daily activities: 3.69 vs 3.49 vs 3.10, P = .003. Fifty-three percent of Group 1 patients exposed to TSN programming utilized peer relationships and 42% read the educational materials provided. Support groups were also popular, with 26% of patients attending at least 1 session. Patients who recalled utilization of TSN services were overall highly satisfied with these services, mean 4.42.

Conclusion:

Patients were overall highly satisfied with their hospital stay, with those exposed to TSN services reporting greater perceived likelihood of recovery and return to daily activities. Development of nontraditional services, including peer visitation and support groups, appears to enhance expectations about recovery.

Feasibility of a Hybrid Web-Based and In-Person Self-management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): A Pilot Randomized Controlled Trial

Objective 1) To assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma) and 2) to evaluate its potential effects at three and six months postinjury. Design A pilot randomized controlled trial (RCT) with two parallel groups. Setting A supraregional level 1 trauma center. Methods Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities. Results More than 80% of eligible patients agreed to participate, and an attrition rate of ≤18% was found. Less than 40% of screened patients were eligible, and obtaining baseline data took 48 hours postadmission on average. Mean scores of mild pain intensity and pain interference with daily activities (<4/10) on average were obtained in both groups at three and six months postinjury. Between 20% and 30% of participants reported moderate to high mean scores (≥4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at three months postinjury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30) and anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained through the end of the study. Conclusions Some challenges that need to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.

Bundling Interventions to Enhance Pain Care Quality (BITE Pain) in Medical Surgical Patients

Background: Inadequate pain management and undertreatment remain a serious clinical issue among hospitalized adults, contributing to chronic pain syndromes and opioid dependency. Implementation of individual pain care interventions has been insufficient to improve pain care quality. The purpose of this interprofessional, patient-centered project was to implement a 6-component bundle of evidence-based pain management strategies to improve patients' perception of pain care quality and 24-hour pain experience outcomes. Methods: A quasi-experimental design was used to test the effect of a bundled pain management intervention on 3 medical surgical units. Baseline outcomes using the Pain Care Quality-Interdisciplinary (PainCQ-I^©) and Pain Care Quality-Nursing (PainCQ-N^©) surveys were measured monthly for 4 months preintervention and 30 months postintervention. Results: A convenience sample of 846 patients was analyzed. The effect of the intervention on pain outcomes could not be tested because unit-based adherence did not meet the goal of 80%. A subsample of 70.2% (594/846) of participants was sufficient to complete a 3-group analysis of preintervention and postintervention participants with confirmed intervention adherence. Participants in the postintervention group who received all 6 components (n=65) had significantly higher odds of higher PainCQ^© scores than those in the preintervention group (n=141) (PainCQ-I^©: odds ratio [OR] 2.61, 95% confidence interval [CI] 1.54-4.42; PainCQ-N^©: OR 3.82, 95% CI 2.06-7.09) or those in the postintervention group receiving ≤5 components (n=388) (PainCQ-I^©: OR 2.52, 95% CI 1.57-4.03; PainCQ-N^©: OR 3.84, 95% CI 2.17-6.80). Conclusion: Medical surgical patients participating in this study who received the bundled 6-component intervention reported significantly higher levels of perceived pain care quality, suggesting that a bundled approach may be more beneficial than unstandardized strategies.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

The Importance and Extent of Providing Compassionate Nursing Care from The Viewpoint of Patients Hospitalized in Educational Hospitals in Kermanshah - Iran 2017

AIM

This study is an attempt to determine the importance and extent of providing compassionate nursing care from the hospitalised patients' viewpoint in educational hospitals in Kermanshah-Iran 2017.

METHODS

The study was carried out as a descriptive, analytical work in the hospitals affiliated to Kermanshah University of Medical Sciences on 300 patients in 2017. The patients were selected through convenient sampling, and Burnell Compassionate Care Scale was filled by the participants. The collected data was analysed in SPSS (v.20) using descriptive and inferential statistics.

RESULTS

The results showed that the mean and standard deviation score of importance and extent of compassionate care were 3.27 ± 0.526 and 2.80 ± 0.647 respectively. There was a significant difference between these two scores (p < 0.001). About all the factors in compassionate nursing care, there was a significant difference between the importance and extent of compassionate nursing care. The mean score of the importance of compassionate nursing care from female patients' viewpoint was higher than that of men (p = 0.032). The observers with college educations perceived the extent of compassionate nursing care less than the other groups of participants (p = 0.008).

CONCLUSIONS

There was a significant difference between the importance and extent of compassionate nursing care from the patients' point of view. This highlights negligence by the nurses of this critical aspect of care. It is recommended, therefore, to add compassionate nursing care to nursing programs and commission more research works on other groups of health care personnel.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma

Importance

Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population.

Objectives

To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes.

Design, Setting, and Participants

A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018.

Main Outcomes and Measures

At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months.

Results

Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups.

Conclusions and Relevance

This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

The clinical utility of repetitive transcranial magnetic stimulation in reducing the risks of transitioning from acute to chronic pain in traumatically injured patients

Pain is a multifaceted condition and a major ongoing challenge for healthcare professionals having to treat patients in whom pain put them at risk of developing other conditions. Significant efforts have been invested in both clinical and research settings in an attempt to demystify the mechanisms at stake and develop optimal treatments as well as to reduce individual and societal costs. It is now universally accepted that neuroinflammation and central sensitization are two key underlying factors causing pain chronification as they result from maladaptive central nervous system plasticity. Recent research has shown that the mechanisms of action of repetitive transcranial magnetic stimulation (rTMS) make it a particularly promising avenue in treating various pain conditions. This review will first discuss the contribution of neuroinflammation and central sensitization in the transition from acute to chronic pain in traumatically injured patients. A detailed discussion on how rTMS may allow the restoration from maladaptive plasticity in addition to breaking down the chain of events leading to pain chronification will follow. Lastly, this review will provide a theoretical framework of what might constitute optimal rTMS modalities in dealing with pain symptoms in traumatically injured patients based on an integrated perspective of the physiopathological mechanisms underlying pain.

AAPT Diagnostic Criteria for Peripheral Neuropathic Pain: Focal and Segmental Disorders

Peripheral neuropathic pain is among the most prevalent types of neuropathic pain. No comprehensive peripheral neuropathic pain classification system that incorporates contemporary clinical, diagnostic, biological, and psychological information exists. To address this need, this article covers the taxonomy for 4 focal or segmental peripheral neuropathic pain disorders, as part of the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership and the American Pain Society (APS) collaborative to develop a standardized, evidence-based taxonomy initiative: the ACTTION-APS Pain Taxonomy (AAPT). The disorders-postherpetic neuralgia, persistent posttraumatic neuropathic pain, complex regional pain disorder, and trigeminal neuralgia-were selected because of their clinical and clinical research relevance. The multidimensional features of the taxonomy are suitable for clinical trials and can also facilitate hypothesis-driven case-control and cohort epidemiologic studies. PERSPECTIVE: The AAPT peripheral neuropathic pain taxonomy subdivides the peripheral neuropathic pain disorders into those that are generalized and symmetric and those that are focal or segmental and asymmetric. In this article, we cover the focal and segmental disorders: postherpetic neuralgia, persistent posttraumatic neuropathic pain, complex regional pain disorder, and trigeminal neuralgia. The taxonomy is evidence-based and multidimensional, with the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.

Change in Pain Score after Administration of Analgesics for Lower Extremity Fracture Pain during Hospitalization

BACKGROUND

Effective acute pain management following injury is critical to improve short-and long-term patient outcomes. Analgesics can effectively reduce pain intensity, yet half of injury patients report moderate to severe pain during hospitalization.

PURPOSE

The primary aim of this study was to identify the analgesic, different analgesic combinations, or analgesic and adjuvant analgesic combination that generated the largest percent change from pre- to post-analgesic pain score.

DESIGN

This was a descriptive retrospective cohort study of 129 adults admitted with lower extremity fractures to a trauma center.

METHODS

Name, dose, and frequency of analgesics and adjuvant analgesics administered from admission to discharge were collected from medical records. Percent change was calculated from pain scores documented on the 0-10 numeric rating scale.

RESULTS

The analgesic with largest percent change from pre- to post-administration pain score was hydromorphone 2 mg IV (53%) for the emergency department and morphine 4 mg IV (54%) for the in-patient unit. All analgesics administered in the emergency department and ∼50% administered on the in-patient unit produced a minimal (15%) decrease in pain score.

CONCLUSIONS

This study revealed that few analgesics administered in the emergency department and the in-patient unit to patients with lower extremity fractures provide adequate pain relief. In the emergency department, all analgesics administered resulted in at least minimal improvement of pain. On the in-patient unit 13 analgesic doses resulted at least minimal improvement in pain while nine doses did not even reach 20% change in pain. Findings from this study can be used guide the treatment of fracture pain in the hospital.

Analgesics Administered for Pain During Hospitalization Following Lower Extremity Fracture: A Review of the Literature

Effective treatment of acute pain during hospitalization following lower extremity fracture is critical to improve short-term patient outcomes including wound healing, stress response, hospital length of stay, and cost as well as minimizing long-term negative patient outcomes such as delayed return to work, disability, and chronic pain. As many patients report moderate to severe pain during hospitalization, identifying the analgesics that most effectively reduces pain is a priority to improve patient outcomes. The purpose of this review was to examine published studies describing patient response to analgesics administered orally (PO) or intravenously (IV) in the immediate hospitalization following lower extremity fracture. PubMed was queried for articles published through May 2017 that included information on type of study, population, fracture site, pain measurement tool, analgesic, and result. Of 514 articles found, eight met the inclusion criteria. Analgesics administered PO or IV were fentanyl, hydromorphone, morphine, remifentanil, diclofenac, ibuprofen, ketorolac, and etoricoxib. Five of the studies focused on comparisons between one or more analgesics and three studies compared an IV analgesic to a regional anesthetic agent. Two studies compared different nonsteroidal anti-inflammatory drugs (NSAIDs). Bupivacaine, lignocaine, and levobupivacaine administered as regional nerve blocks were superior to controlling pain compared with IV fentanyl and IV hydromorphone. IV morphine provided faster and better pain relief compared with IV ibuprofen. Based on the limited data available, regional nerve blocks provided superior pain relief compared with opioids, and opioids provided superior pain relief compared with NSAIDs. Different NSAIDs provided similar pain relief.

The Nature of Trauma Pain and Its Association with Catastrophizing and Sleep

BACKGROUND

Nearly 2.8 million people are hospitalized in the USA annually for traumatic injuries, which include orthopedic and internal organ injuries. Early post-injury pain is predictive of poor outcomes, including inability to eventually return to work, and long-term psychological distress. The goal of the present study was to improve our scientific understanding of trauma-related pain by examining (1) the nature and frequency of inpatient trauma pain and (2) the associations between inpatient trauma pain, education, opioid analgesic equivalent use, pain catastrophizing, and sleep quality.

METHOD

The study included 120 patients hospitalized at a major level I regional trauma center for the care of (1) closed long bone or calcaneus fractures and/or (2) an intraabdominal injury caused by blunt force trauma and requiring surgical repair (i.e., laparotomy). Medical records were reviewed to obtain demographic information and information about opioid use during hospitalization. In addition, participants were administered measures of average pain intensity, pain catastrophizing, and sleep quality.

RESULTS

Education, opioid analgesic equivalents, catastrophizing, and poor sleep quality together accounted for 28% of the variance of average pain intensity over a 24-h period (p < .001), with each variable making a significant independent association.

CONCLUSION

Two of the factors associated with pain intensity in the study sample-catastrophizing and sleep quality-are modifiable. It is therefore possible that interventions that target these variables in patients who are hospitalized for trauma could potentially result in better long-term outcomes, including a reduced risk for developing chronic pain. Research to evaluate this possibility is warranted.

Development and Acceptability Assessment of a Self-Management Intervention to Prevent Acute to Chronic Pain Transition after Major Lower Extremity Trauma

PURPOSE

Transition from acute to chronic pain often occurs after major lower extremity trauma. Chronic pain has been found to negatively affect daily functioning, including the capacity to work and quality of life. Empirical data and an acceptability assessment were used to develop a self-management intervention aimed at preventing acute to chronic pain transition after major lower extremity trauma (i.e., iPACT-E-Trauma).

METHODS

Evidence from previous studies on preventive self-management interventions, combined with a biopsychosocial conceptual framework and clinical knowledge, helped define the key features of the preliminary version. Then a mixed-methods design was used to assess the acceptability of iPACT-E-Trauma by clinicians and patients.

RESULTS

The key features of the preliminary version of iPACT-E-Trauma were assessed as acceptable to very acceptable by clinicians and patients. After clinician assessment, intervention activities were simplified and session duration was reduced. Patient acceptability assessment of iPACT-E-Trauma led to the tailoring of key intervention features, based on determinants such as pain intensity and the implementation of self-management behaviors between intervention sessions. Web-based sessions were also developed to facilitate iPACT-E-Trauma delivery.

CONCLUSION

This study outlines the process involved in the development of an intervention to prevent chronic pain in patients with lower extremity trauma. Relevant information is provided to nurses and interdisciplinary teams on a self-management intervention to prevent the transition from acute to chronic pain in the trauma population.