Pain-related psychological distress, self-rated health and significance of neuropathic pain in Danish soldiers injured in Afghanistan

A systematic review of the prevalence of postamputation and chronic neuropathic pain associated with combat injury in military personnel

ABSTRACT

Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.

The effect of neuropathic pain on quality of life, depression levels, and sleep quality in patients with combat-related extremity injuries

Purpose

There is limited research on the effects of neuropathic pain (NP) on quality of life, depression levels, and sleep quality in patients with combat-related extremity injuries. This study evaluated whether patients with combat-related extremity injuries with and without NP had differences in quality of life, sleep quality, and depression levels.

Methods

A total of 98 patients with combat-related extremity injuries, 52 with NP and 46 without, were included in this cross-sectional study. The presence of NP was determined using the Leeds Assessment of Neuropathic Symptoms and Signs questionnaire. The outcome measures were a visual analogue scale (VAS), the 36-Item Short Form Survey, the Beck Depression Inventory, and the Pittsburgh Sleep Quality Index (PSQI).

Results

The VAS subparameter scores for pain (all P<0.05), PSQI sleep duration subscale scores (P=0.025), PSQI sleep disturbance subscale scores (P=0.016), and PSQI total scores (P=0.020) were significantly higher in patients with NP than those without. Logistic regression analysis showed that VAS scores of 5 and above for average pain during the previous 4 weeks contributed independently to the prediction of NP.

Conclusions

Patients with combat-related extremity injuries with NP had more pain and poorer sleep quality than those without NP. Sleep quality should be evaluated as part of the diagnostic work-up in patients with combat-related extremity injury with NP, and interventions to improve sleep quality may help manage NP in this patient group.

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.

Single-Item, Self-Rated Health is a Useful Indicator of Health in Myofascial Temporomandibular Disorders

Aims:

To (1) examine differences in self-rated health (SRH) between a group of women with myofascial temporomandibular disorders (mTMD) and controls; (2) determine the extent to which pain, mental health, and physical function mediate these differences; and (3) explore specific mTMD symptoms and impairments explaining SRH among mTMD cases.

Methods:

An existing dataset of a sample of women with mTMD (n = 125) and a group of demographically similar controls (n = 49) was used. SRH was measured via a single item with 5 answer options ranging from poor (SRH = 1) to excellent (SRH = 5). Bodily pain, mental health, and physical function were measured with the Short-Form Health Survey. Regression analyses with SRH as the outcome were conducted.

Results:

mTMD cases reported poorer SRH compared to controls, and bodily pain score fully mediated these lower scores. Physical function partially mediated the association between mTMD and SRH, while mental health did not explain much of the variance in SRH. This pattern held in case-only analyses. The association was not explained by mTMD-specific symptoms or by localized mTMD pain severity, although mTMD disability was independently associated with lower SRH.

Conclusion:

SRH is a simple and useful tool to consider in mTMD research, as it discriminates between cases and controls based on pain and physical function and is associated with mTMD disability.

Neuropathic pain after sarcoma surgery: Prevalence and predisposing factors

Surgery for sarcoma frequently causes nerve damage as the dissection often violates the internervous plane. Nerve damage may cause neuropathic pain (NP), which can result in persistent pain after surgery. This is the first study to investigate the prevalence and associated factors of postoperative NP in patients who underwent surgery for sarcoma of the extremities or pelvis.Patients (n = 144) who underwent curative surgery at least 6 months prior to the visit for histologically confirmed sarcoma were enrolled. The presence of NP was assessed by administering PainDetect, a widely used questionnaire for detecting NP. Patients with PainDetect scores ≥13 were considered to have NP. The possible factors that might be associated with the development of NP were investigated: patient characteristics, tumor characteristics, extent of surgery, and adjuvant therapy.Out of 144 patients, 36 patients (25%) had NP. Patients with NP had significantly worse visual analog scale score (P < .001), Toronto Extremity Salvage Score (P < .001), and Musculoskeletal Tumor Society Rating Scale score (P < .001) than patients without NP. Among the possible factors associated with NP, patients with NP were more likely to have undergone pelvic surgery (P = .002) and multiple surgeries (P = .014) than patients without NP. In logistic regression analysis, pelvic surgery (odds ratio = 5.05, P = .005) and multiple surgeries (odds ratio = 2.33, P = .038) were independent factors associated with NP after sarcoma surgery.This study suggests that the prevalence of NP after surgery for sarcoma is considerable. Surgery of the pelvis and multiple surgeries are predictive of postoperative persistent NP.

Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties

Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.