Assessment and Treatment of Pain Associated with Combat-Related Polytrauma

Abstract

Due to the high rates of blast injuries sustained during operations in Iraq and Afghanistan, the number of soldiers returning with massive and multiple wounds is unprecedented. While casualty survival rates have improved dramatically, the extent and impact of these wounds on soldiers' functioning pose unique challenges for their rehabilitation. Pain is highly prevalent in these individuals with polytrauma injuries and is a source of suffering, as well as an impediment to rehabilitation. However, there are a number of obstacles to effective pain treatment in this group of war-injured, including their multiple and severe injuries, the high prevalence of brain injuries, cognitive impairments and emotional distress, the prolonged and intensive rehabilitation process, and the frequent need for repeated follow-up surgeries. As a result, we believe that a comprehensive, interdisciplinary approach to pain treatment is required. In this article we describe the model of pain care that has evolved at the Tampa Polytrauma Rehabilitation Center, which incorporates medical, rehabilitative, cognitive-behavioral, and interventional treatments targeting pain intensity as well as pain-related impairments and coping. We include a case study illustrating some key aspects of our approach.

Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad

“…In another study of 50 OIF/OEF veterans treated at a Level 1 PRC, 80 percent incurred a combat-related TBI, 96 percent reported at least one pain problem, and 44 percent reported experiencing PTSD [5]. Clark and colleagues discussed the complex array of pain issues and the challenges related to the reliable assessment and care management of servicemembers being seen in the PRC [14]. Lew et al found that in a sample of the first 62 patients evaluated at a Level 2 PNS, 97 percent reported three or more PPCS (i.e., headache, dizziness, fatigue), 97 percent complained of chronic pain, and 71 percent met criteria for PTSD [4].…”

Innovations in the En Route Care of Combat Casualties

“…Accurate pain assessment is a necessary precursor to effective pain management. However, pain assessment can be challenging in polytrauma patients, especially in those with severe head injury, cognitive impairment, and multiple wounds (Clark, Scholten, Walker, & Gironda, 2009). The environment of the aircraft adds additional diffi culties to the assessment and documentation of pain.…”

Stem cell applications in military medicine

“…Nearly all tissues are of military interest, due to the diverse nature of injuries associated with war trauma (Figure 2). The increase in explosive attacks in current conflicts often results in massive wounds involving multiple organs [13], making all realms of tissue reconstitution a primary goal of military stem cell applications. To properly engineer complex tissues, stem cells will likely need to be augmented by biomaterials, which are not discussed in detail here (the authors recommend the following reviews: opinion on importance of synthetic biomaterials in tissue engineering [14]; current commercial biomaterials and future perspectives [15]; nerve guides [16]).…”

“…Fracture stabilization, repair of vascular injury and tissue debridement often take precedence over nerve repair, and may lead to delays in addressing damaged nerves, further complicating peripheral nerve treatment [28]. In any type of nervous tissue injury, there is typically neuropathic pain, experienced as sharp, burning or stabbing sensations, which combined with limited motor recovery and subsequently limited functional recovery makes even partial restoration a clear goal [13]. …”