Screening for Acute Factors That Predict Pain Post Trauma:

A Pilot Study

Allyson Browne, Kim Fong, Sudhakar Rao, Fiona Wood, Stephan Schug

Royal Perth HospitalUniversity of Western Australia

Aims

Test a model of screening for pain and psychological risk factors in a trauma setting

Identify risk factors for pain and psychological outcomes following trauma

Pain After Traumatic Injury

Traumatic injury has been proposed as either a causal factor or trigger of chronic pain.

Buskila & Neumann (2000); Staud (2004)

More than 40% of patients with limb threatening lower extremity trauma reported clinically significant pain intensity at 7 years post trauma. Castillo et al (2006)

What Predicts Persistent Pain Following Trauma?

High levels of acute & post surgical pain have been linked to increased risk of persistent pain.

Gehling, et al (1999); Perkins & Kehlet (2000)

Growing consensus that chronic pain may be the result of Central Neuroplasticity.

Siddall & Cousins (2004) Woolf (1995)

Converging evidence suggesting that the onset of persistent pain post trauma is independent to injury characteristics and surgical decisions

Jenewein et al (2009) Castillo et al (2006) Ashburn & Fine (1989)

Predicting Pain Post Trauma Study Group &

Trauma PopulationsFollow-Up Number

(% attrition)

Time Frame

Acute Predictors Outcomes Outcome Measures

Williamson et al (2009)

Orthopaedic

1290 (45%)*

*% of available sample

6 Mo Low education

Comp status

Pain severity

Pain disability Hx

Pain Intensity

Pain Disability

Anxiety

Depression

VAS 11 point

SF12 (QoL)

Castillo et al (2006)

Lower Limb

397 (28%) 7 years Low education

Low self efficacy

Alcohol Hx

Pain at 3/12

Insomnia 3/12

Depress / Anx 3/12

Pain Intensity

Pain Interference

Graded Chronic Pain Questionnaire

Corry et al (2009)

Edwards et al (2007)

Burns

171 (48%)

249 (53%)

2 Years

2 Years

PTSD but not Pain

Depression but not Anxiety

Physical Fn

Physical Role

Pain

Physical Fn

SF 36

SF 36

Jenewein et al (2009)

Holmes et al (2010)

Heterogenous

90 (26%)

242 (17%)

3 Years

3 Mo

PTSD

Length of Stay

Somatization

Age, Gender

Alcohol Hx

Physical Fn Hx

Pain severity

Morphine

Presence of Pain

Disability

Health Care Use

Med Use

Pain Intensity

Clinical Interview

VAS 11 point

Trauma Pain as Distinct to CLBP Pain experience associated with recent life or serious injury threat.

People who attribute pain symptoms to injury are more likely to view any sensation as harmful, thereby increasing anxiety and avoidance behaviour.

Turk et al (1996)

PTSD symptoms have been shown topredict pain symptom severity post trauma.

Sterling et al (2005) Jenewein et al (2009)

Linking Pain and PTSD Post Trauma PTSD and depression occur 10 and 3 times more often respectively within 12

months of injury among Australian trauma survivors compared with community

samples. O’Donnell et al (2004)

Centrality of threat-expectancy, hypervigilance, and fear avoidance is common

to both pain and traumatic stress evolution. Sharp & Harvey (2001)

Stress response system dysregulation is common feature to both PTSD and

fibromyalgia developing after MVA. McLean et al (2005)

• Trauma patients with PTSD at 3 months post injury received less morphine than

those who did not develop PTSD. Bryant et al (2009)

Baseline Predictors

(< 1 mo)Demographic

Age

Gender

Education

Compensation Status

Employment Status

Rural vs Metro

Injury & Surgery Related

ISS

Mechanism of Injury

Number Surgeries

Amputation/Prosthesis

Type of Injury

Pain Severity & Quality

Analgesia

Psychological

Acute PTSD symptoms

Posttraumatic Adjustment

Depression

Self-Efficacy for Coping with Pain

Alcohol Consumption

Mental Health History

Outcomes

(6 Mo)Functional

Return to Work

Compensation Status

Activities of Daily Living

Financial Impact

Health Care Use

Physical

Mobility

Balance

Pain Severity & Quality

Pain Related Disability

Psychological

PTSD Sx & Diag

Depression Sx & Diag

Alcohol Consumption

Patient Satisfaction

Measures

(6 Mo)Functional

Clinical Interview

Functional Independence

Measure (ADLs)

Physical

6 Minute Walk Test

Berg Balance Scale

Pain Detect

Brief Pain Inventory

Clinical Interview

Psychological

Posttraumatic Checklist Civilians

Centre Epidemiological Studies

Depression Scale

AUDIT

Patient Satisfaction Quest

MINI Diagnostic Interview

Methods

All new trauma admissions identified with LOS > 24 hrs.

Excluded:Moderate/Severe Head Injury

PTA > 24 hrs or GCS < 13 at admissionSevere ETOH DependenceHigh Suicidal RiskOverseas or Interstate Visitor

Non-English Speaking

Risk Screening within 1 Month Post Injury: Medical file reviewSemi-Structured Clinical Interviews Standardised self report measures

Excluded (n=27)Did not consent (n = 27)

Consented and screened(n=149)

Excluded(n=7)Screening not completed (n=3)Not ‘at risk’ (n = 2)Moderate head injury (n=1)Age < 18 years (n=1)

Randomised(n=142)

Allocated to MCC (n=69) Allocated to UC (n=73)

Excluded (n =15)Discharged from hospital (n=8)Moderate head injury (n=3)Currently actively suicidal (n = 2)Intoxicated/Withdrawal (n=1)Age < 18 years (n=1)

Approached for consent(n=176)

Assessed for eligibility(n = 191)

Analysed 6 Month outcomes (n=67)Lost to follow up (n =75)Working (n=6)Remote location (n=6)Unable to contact (n=50)Discontinued (n=1)Withdrawn (n=2)Incomplete data (n=10)

Recruitment Flow

Chart

Attrition 53% at 6 Months

Screening Feasibility & Follow-Up

Approximately 11% of eligible admissions were screened within the recruitment phase.

Staffing limited to 1 part-time research assistant.

High attrition at 6 months associated with high alcohol consumption at baseline, male, younger age.

Sample Characteristics Mean Age = 36 years (SD = 15.57)

Mean ISS = 9.65 (SD = 3.82)

Mdn LOS = 13 days (SD = 11.93)

74% male

20% prior psych diagnosis

15% positive suicide risk

81% employed

Fall9%

MVA41%

MBA29%

Assault7%

Other4%

Work4%

Sport6%

Mechanism of Injury

Clinical Characteristics

Upper Limb4%

Lower Limb27%

Back4%

Chest4%

Spinal12%

Internal4%

Pelvis8%

Face5%

Multi32%

Type of Injury

• 72% (n = 92) Surgery

• 92 % (n = 87) GA

• 4% (n = 5) Amputation

• 11.7% Wound Infection

• 30% ETOH related injury

Baseline Pain & Psychological Factors

20.4

49.3

15

51.4

40.1

26.8

47.7

0

10

20

30

40

50

60

Neuro

pathic

Pai

n

Moder

ate/

Sever

e Ave

rage

Pain

Low Pai

n Confid

ence

At Ris

k PTSD/D

epre

ssio

n

Depre

ssiv

e sy

mpt

oms

PTSD s

ympto

ms

Harm

ful E

TOH U

se

%

Baseline & 6 Month Findings

20.4

49.3

15

40.1

26.8

47.7

12.3

30.8

12.9

32.3

21.5

30.2

0

10

20

30

40

50

60

%

Baseline

Six Months

6 Month Clinical Findings

• 42% diagnosed with pain related disability by Pain Specialist.

• 10% & 15% diagnosed with Depression & PTSD respectively.

• 15% diagnosed with comorbid Depression & PTSD.

Predicting PTSD at 6 Months

Final Step and Acute Predictors β t ∆R2 ∆F

2.2. Age Age GenderGender Injury SeverityInjury Severity Trial GroupTrial Group Acute Traumatic StressAcute Traumatic Stress Acute DepressionAcute Depression Posttraumatic Adjustment Alcohol Use Average Pain Severity Neuropathic symptoms

.10.10

.10.10-.02-.02-.02-.02.13.13.04.04.51.38-.40.22

1.281.281.311.31-.20-.20-.27-.271.271.27.38.38

5.08***4.82***-5.05***

2.54*

.70.70 .22.85***.22.85***

*p < .05, ***p < .001

Acute psychological, pain, and alcohol use predicted 70% of the variance in PTSD symptom severity at 6 months after controlling for age, gender, and injury severity.

Predicting Pain at 6 MonthsFinal Step and Predictors β t ∆R2 ∆F

2.2. Age Age GenderGender Injury SeverityInjury Severity Trial GroupTrial Group Acute Traumatic StressAcute Traumatic Stress Acute DepressionAcute Depression Posttraumatic Adjustment Alcohol UseAlcohol Use Average Pain SeverityAverage Pain Severity Neuropathic symptoms

-.03-.03-.17-.17-.08-.08-.09-.09.03.03-.23-.23.33.15.15.07.07.33

-.22-.22-1.38-1.38-.61-.61-.70-.70.21.21

-1.32-1.322.02*1.161.16.55.55

2.44*

.27.27 3.24*3.24*

*p < .05

Acute psychological, pain, and alcohol use predicted 27% of the variance in pain severity at 6 months after controlling for age, gender, and injury severity.

Predicting Physical Function at 6 Months

Final Step and Acute Predictors β t ∆R2 ∆F

2.2. Age Age GenderGender Injury Severity Trial GroupTrial Group Acute Traumatic StressAcute Traumatic Stress Acute DepressionAcute Depression Posttraumatic Adjustment Average Pain Severity Alcohol UseAlcohol Use

-.14-.14.03.03-.34..0909.16.16-.36-.36-.49.44.10.10

-1.12-1.12.21.21

-2.81*.80.80.99.99

-2.12-2.12-3.10**3.47**

.79.79

.45.45 6.75***6.75***

Acute psychological, pain, and alcohol use predicted 45% of the variance in mobility at 6 months after controlling for age, gender, and injury severity.

*p < .05, **p<.01, ***p < .001

Key Findings

A small proportion of eligible patients were screened by research staff

The prevalence of clinically significant pain and psychopathology was high at both baseline and 6 months

Standardised measures of acute pain, alcohol, and posttraumatic responses predicted variance in subsequent pain, psychological, and physical outcomes

Implications

Trauma Committee of RACS refers to 2007 ANZCA ‘Guidelines on Acute Pain Management’

ANZCA Guidelines: Regular assessment of pain during rest and activity using patient self report, regular evaluation of effectiveness of acute pain management.

Translation of the guidelines & application of research evidence in acute trauma settings?

Future Directions

Larger scale prospective multi-site studies required

Standardized multidisciplinary measures of both predictors and outcomes required

Further feasibility studies required to examine implementation of pain and post trauma hospital wide screening tools

A new trauma-specific model of persistent pain evolution?

Dr Allyson BrowneDr Allyson Browneallyson.browne@uwa.edu.auUniversity of Western AustraliaUniversity of Western Australia