Pain Management in the Severely Impaired Polytrauma Patient Entering Rehabilitation
Joel Scholten, MD
Physical Medicine and Rehabilitation

James A. Haley Veterans Hospital
Tampa, Florida
The Polytrauma Rehab Center
The four Polytrauma Rehabilitation Centers (PRC’ s) are inpatient rehabilitation programs that have been treating combat related polytrauma patients since early 2003.
The PRCs utilize an interdisciplinary approach to assess and treat the entire range of impairments and needs of the combat wounded and their families.
Pain assessment and management is recognized as an important component of rehabilitative care
The Polytrauma Patient
Injuries to multiple areas of the body involving multiple organ systems resulting in significant functional impairment.
The traumatic brain injury is usually the driving factor for rehabilitation.

Traditional Rehab Team
PM&RS Attending Physician
Physical Therapy
Occupational Therapy
Speech Therapy
Recreational Therapy
Psychology
Nursing
Prosthetics
Social Work
Polytrauma Team Approach in Tampa
Traditional Rehabilitation Team Plus:
Multidisciplinary Team Rounds
Twice weekly multidisciplinary rounds
Chief of PM&R and SCI, SCI and PM&R Attending, Internal Medicine, Infectious Disease, Surgery, Nursing, Infection Control, Case Managers, Utilization Review, Pain Management
Discuss ongoing medical needs, pain management, psychosocial issues, military needs
Polytrauma Team Approach in Tampa
Pain Psychologist
Close interdependent collaboration with PM&R
PTSD Psychologist
Tampa Polytrauma Pain Team
Pain Psychologist:
attends polytrauma medical rounds
comprehensive documentation of pain problems
serves on clinical and administrative teams
provides assessment and treatment services
offers consultative and educational services to staff

Tampa Polytrauma Pain Team

Pain Medical Management Consultation:
pain medication and medication adjustments
opioid pain medication tapers
Pain Intervention Consultation:
ESIs, Nerve Blocks, and Pump implantations

Tampa Polytrauma Pain Team
Physicians
Education
Medical assessment and treatment of pain
Chiropractics
Acupuncture
Injections
Physical and Occupational Therapy
Modalities
Therapies

Tampa Polytrauma Pain Team
Nursing Staff
Assessment and treatment of pain
Education to patient and family
Psychosocial support
Recreational therapy
Diversional activities

Polytrauma Pain Management
Early and continued treatment
To minimize likelihood of chronic pain problems

Multidisciplinary in nature
Behavioral
Pain Psychologist
Therapists
Nursing
Family/Friends
Medical
R/O and manage causes
Medications
Opioid reductions
Transfer of Rx between MTF and VA

Polytrauma Pain Management
Multidisciplinary in nature (continued)
Interventional
Needed less frequently than meds and behavioral
ESIs, Nerve Blocks, Pump Implantations
Therapies and Modalities
PT
OT
RT
Acupuncture
Chiropractics

Pain Assessment
Challenging in Low Level Patients
Utilize Family and Staff for comprehensive assessment of pain and impact on function
Utilize descriptors to help differentiate type of pain :
Musculoskeletal pain NeuropathicPain
Aching, Dull sharp, electric
Throbbing shooting, stabbing

Musculoskeletal Pain
Spasticity
ROM and stretching- involve family, therapists and nursing
Modalities- ice, heat
Renew current meds
Anti-spasticity meds- dantrolene, baclofen, tizanadine
Botox, Nerve Blocks
Contractures
Prevention is key! Range of Motion
Serial Casting and Bracing/Splints

Musculoskeletal Pain
Heterotopic Ossification (H.O.)- calcification of soft tissues
Elevated alkaline phosphatase
Bone scan for early diagnosis, plain films are positive once significant calcification has occurred
Indocin and Didronel
Radiation therapy can also be used
Surgical Resection only when H.O. is mature, usually after 18 months
Musculoskeletal Pain
Fractures- missed diagnosis
Sprains/Strains
Dislocation/Subluxation
Impingement
Skin- decubitis ulcers, etc.
Stump pain
Musculoskeletal Pain- Treatment
Exercise, Range of Motion, Massage
Modalities- TENS, Ultrasound, Heat, Cold
Topical Medications- Capsaicin, etc.
NSAIDS
Anti-spasticity meds- dantrolene, baclofen, tizanadine
Narcotics
Acupunture, Chiropractic manipulation
Neuropathic Pain
Peripheral Nerve/ Plexus Injury
Complex Regional Pain Syndrome/RSD
Central Pain
Phantom Pain
Neuropathic Pain- Treatment
Most medications used for treatment of Neuropathic pain do not have FDA approval for this use.
Antidepressants
Antiepileptic Meds
TENS
Modalities-Contrast Baths, etc
Interventional Techniques- epidural injections, sympathetic blocks
Pain due to Burns
Initial Pain Management for Burns includes significant amount of narcotic
During Rehab Phase monitor pain level and function, attempt to minimize need for breakthrough pain medications
Other Pain
Don’ t blame pain on the TBI
Cardiac pain
Abdominal pathology
Review mechanism of event and other injuries that occurred at the time of the initial event ie. Abdominal trauma, etc.
Pain Management Goals
Improve Comfort AND Function
Correlate Pain Score with Function
Minimize Cognitive Side Effects
Avoid Poly-pharmacy
Assess and monitor effect of intervention
Involve the Patient and Family

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