pain management in the severely impaired polytrauma patient entering rehabilitation joel scholten,...
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Pain Management in the Severely Impaired Polytrauma Patient
Entering Rehabilitation
Pain Management in the Severely Impaired Polytrauma Patient
Entering Rehabilitation
Joel Scholten, MDJoel Scholten, MDPhysical Medicine and RehabilitationPhysical Medicine and Rehabilitation
James A. Haley Veterans HospitalJames A. Haley Veterans HospitalTampa, FloridaTampa, Florida
Joel Scholten, MDJoel Scholten, MDPhysical Medicine and RehabilitationPhysical Medicine and Rehabilitation
James A. Haley Veterans HospitalJames A. Haley Veterans HospitalTampa, FloridaTampa, Florida
The Polytrauma Rehab CenterThe Polytrauma Rehab Center
• The four Polytrauma Rehabilitation Centers The four Polytrauma Rehabilitation Centers (PRC’s) are inpatient rehabilitation programs (PRC’s) are inpatient rehabilitation programs that have been treating combat related that have been treating combat related polytrauma patients since early 2003.polytrauma patients since early 2003.
• The PRCs utilize an interdisciplinary The PRCs utilize an interdisciplinary approach to assess and treat the entire approach to assess and treat the entire range of impairments and needs of the range of impairments and needs of the combat wounded and their families.combat wounded and their families.
• Pain assessment and management is Pain assessment and management is recognized as an important component of recognized as an important component of rehabilitative carerehabilitative care
• The four Polytrauma Rehabilitation Centers The four Polytrauma Rehabilitation Centers (PRC’s) are inpatient rehabilitation programs (PRC’s) are inpatient rehabilitation programs that have been treating combat related that have been treating combat related polytrauma patients since early 2003.polytrauma patients since early 2003.
• The PRCs utilize an interdisciplinary The PRCs utilize an interdisciplinary approach to assess and treat the entire approach to assess and treat the entire range of impairments and needs of the range of impairments and needs of the combat wounded and their families.combat wounded and their families.
• Pain assessment and management is Pain assessment and management is recognized as an important component of recognized as an important component of rehabilitative carerehabilitative care
The Polytrauma PatientThe Polytrauma Patient
• Injuries to multiple areas of the body Injuries to multiple areas of the body involving multiple organ systems involving multiple organ systems resulting in significant functional resulting in significant functional impairment.impairment.
• The traumatic brain injury is usually The traumatic brain injury is usually the driving factor for rehabilitation.the driving factor for rehabilitation.
• Injuries to multiple areas of the body Injuries to multiple areas of the body involving multiple organ systems involving multiple organ systems resulting in significant functional resulting in significant functional impairment.impairment.
• The traumatic brain injury is usually The traumatic brain injury is usually the driving factor for rehabilitation.the driving factor for rehabilitation.
Traditional Rehab TeamTraditional Rehab Team• PM&RS Attending PM&RS Attending
PhysicianPhysician• Physical TherapyPhysical Therapy• Occupational TherapyOccupational Therapy• Speech TherapySpeech Therapy• Recreational TherapyRecreational Therapy• PsychologyPsychology• NursingNursing• ProstheticsProsthetics• Social WorkSocial Work
• PM&RS Attending PM&RS Attending PhysicianPhysician
• Physical TherapyPhysical Therapy• Occupational TherapyOccupational Therapy• Speech TherapySpeech Therapy• Recreational TherapyRecreational Therapy• PsychologyPsychology• NursingNursing• ProstheticsProsthetics• Social WorkSocial Work
Polytrauma Team Approach in Tampa
Polytrauma Team Approach in Tampa
• Traditional Rehabilitation Traditional Rehabilitation Team Plus:Team Plus:– Multidisciplinary Team RoundsMultidisciplinary Team Rounds
• Twice weekly Twice weekly multidisciplinary roundsmultidisciplinary rounds
• Chief of PM&R and SCI, SCI and Chief of PM&R and SCI, SCI and PM&R Attending, Internal Medicine, PM&R Attending, Internal Medicine, Infectious Disease, Surgery, Nursing, Infectious Disease, Surgery, Nursing, Infection Control, Case Managers, Infection Control, Case Managers, Utilization Review, Pain ManagementUtilization Review, Pain Management
• Discuss ongoing medical needs, pain Discuss ongoing medical needs, pain management, psychosocial issues, management, psychosocial issues, military needsmilitary needs
• Traditional Rehabilitation Traditional Rehabilitation Team Plus:Team Plus:– Multidisciplinary Team RoundsMultidisciplinary Team Rounds
• Twice weekly Twice weekly multidisciplinary roundsmultidisciplinary rounds
• Chief of PM&R and SCI, SCI and Chief of PM&R and SCI, SCI and PM&R Attending, Internal Medicine, PM&R Attending, Internal Medicine, Infectious Disease, Surgery, Nursing, Infectious Disease, Surgery, Nursing, Infection Control, Case Managers, Infection Control, Case Managers, Utilization Review, Pain ManagementUtilization Review, Pain Management
• Discuss ongoing medical needs, pain Discuss ongoing medical needs, pain management, psychosocial issues, management, psychosocial issues, military needsmilitary needs
Polytrauma Team Approach in Tampa
Polytrauma Team Approach in Tampa
– Pain PsychologistPain Psychologist• Close interdependent collaboration Close interdependent collaboration
with PM&Rwith PM&R
– PTSD PsychologistPTSD Psychologist
– Pain PsychologistPain Psychologist• Close interdependent collaboration Close interdependent collaboration
with PM&Rwith PM&R
– PTSD PsychologistPTSD Psychologist
Tampa Polytrauma Pain Team
Tampa Polytrauma Pain Team
• Pain Psychologist:Pain Psychologist:– attends polytrauma medical roundsattends polytrauma medical rounds– comprehensive documentation of pain comprehensive documentation of pain
problems problems – serves on clinical and administrative serves on clinical and administrative
teamsteams– provides assessment and treatment provides assessment and treatment
servicesservices– offers consultative and educational offers consultative and educational
services to staffservices to staff
• Pain Psychologist:Pain Psychologist:– attends polytrauma medical roundsattends polytrauma medical rounds– comprehensive documentation of pain comprehensive documentation of pain
problems problems – serves on clinical and administrative serves on clinical and administrative
teamsteams– provides assessment and treatment provides assessment and treatment
servicesservices– offers consultative and educational offers consultative and educational
services to staffservices to staff
Tampa Polytrauma Pain Team
Tampa Polytrauma Pain Team
• Pain Medical Management Pain Medical Management Consultation:Consultation: – pain medication and medication pain medication and medication
adjustmentsadjustments– opioid pain medication tapersopioid pain medication tapers
• Pain Intervention Consultation:Pain Intervention Consultation:– ESIs, Nerve Blocks, and Pump ESIs, Nerve Blocks, and Pump
implantationsimplantations
• Pain Medical Management Pain Medical Management Consultation:Consultation: – pain medication and medication pain medication and medication
adjustmentsadjustments– opioid pain medication tapersopioid pain medication tapers
• Pain Intervention Consultation:Pain Intervention Consultation:– ESIs, Nerve Blocks, and Pump ESIs, Nerve Blocks, and Pump
implantationsimplantations
• PhysiciansPhysicians– EducationEducation– Medical assessment and Medical assessment and
treatment of paintreatment of pain– ChiropracticsChiropractics– AcupunctureAcupuncture– InjectionsInjections
• Physical and Occupational Physical and Occupational TherapyTherapy– ModalitiesModalities– TherapiesTherapies
• PhysiciansPhysicians– EducationEducation– Medical assessment and Medical assessment and
treatment of paintreatment of pain– ChiropracticsChiropractics– AcupunctureAcupuncture– InjectionsInjections
• Physical and Occupational Physical and Occupational TherapyTherapy– ModalitiesModalities– TherapiesTherapies
Tampa Polytrauma Pain Team
Tampa Polytrauma Pain Team
• Nursing StaffNursing Staff– Assessment and treatment of painAssessment and treatment of pain– Education to patient and familyEducation to patient and family– Psychosocial supportPsychosocial support
• Recreational therapyRecreational therapy– Diversional activitiesDiversional activities
• Nursing StaffNursing Staff– Assessment and treatment of painAssessment and treatment of pain– Education to patient and familyEducation to patient and family– Psychosocial supportPsychosocial support
• Recreational therapyRecreational therapy– Diversional activitiesDiversional activities
Tampa Polytrauma Pain Team
Tampa Polytrauma Pain Team
Polytrauma Pain Management
Polytrauma Pain Management
• Early and continued treatmentEarly and continued treatment– To minimize likelihood of chronic pain problemsTo minimize likelihood of chronic pain problems
• Multidisciplinary in natureMultidisciplinary in nature• Behavioral Behavioral
– Pain PsychologistPain Psychologist– TherapistsTherapists– NursingNursing– Family/FriendsFamily/Friends
• Early and continued treatmentEarly and continued treatment– To minimize likelihood of chronic pain problemsTo minimize likelihood of chronic pain problems
• Multidisciplinary in natureMultidisciplinary in nature• Behavioral Behavioral
– Pain PsychologistPain Psychologist– TherapistsTherapists– NursingNursing– Family/FriendsFamily/Friends
• MedicalMedical– R/O and R/O and
manage causesmanage causes– MedicationsMedications
• Opioid reductionsOpioid reductions• Transfer of Rx Transfer of Rx
between MTF between MTF and VAand VA
• MedicalMedical– R/O and R/O and
manage causesmanage causes– MedicationsMedications
• Opioid reductionsOpioid reductions• Transfer of Rx Transfer of Rx
between MTF between MTF and VAand VA
• Multidisciplinary in nature Multidisciplinary in nature (continued)(continued)– InterventionalInterventional
• Needed less frequently than meds Needed less frequently than meds and behavioraland behavioral
• ESIs, Nerve Blocks, Pump ESIs, Nerve Blocks, Pump ImplantationsImplantations
– Therapies and ModalitiesTherapies and Modalities• PTPT• OTOT• RTRT• AcupunctureAcupuncture• ChiropracticsChiropractics
• Multidisciplinary in nature Multidisciplinary in nature (continued)(continued)– InterventionalInterventional
• Needed less frequently than meds Needed less frequently than meds and behavioraland behavioral
• ESIs, Nerve Blocks, Pump ESIs, Nerve Blocks, Pump ImplantationsImplantations
– Therapies and ModalitiesTherapies and Modalities• PTPT• OTOT• RTRT• AcupunctureAcupuncture• ChiropracticsChiropractics
Polytrauma Pain Management
Polytrauma Pain Management
Pain AssessmentPain Assessment• Challenging in Low Level PatientsChallenging in Low Level Patients• Utilize Family and Staff for comprehensive Utilize Family and Staff for comprehensive
assessment of pain and impact on functionassessment of pain and impact on function• Utilize descriptors to help differentiate type Utilize descriptors to help differentiate type
of pain :of pain :Musculoskeletal painMusculoskeletal pain NeuropathicPainNeuropathicPain
Aching, DullAching, Dull sharp, electricsharp, electricThrobbingThrobbing shooting, stabbingshooting, stabbing
• Challenging in Low Level PatientsChallenging in Low Level Patients• Utilize Family and Staff for comprehensive Utilize Family and Staff for comprehensive
assessment of pain and impact on functionassessment of pain and impact on function• Utilize descriptors to help differentiate type Utilize descriptors to help differentiate type
of pain :of pain :Musculoskeletal painMusculoskeletal pain NeuropathicPainNeuropathicPain
Aching, DullAching, Dull sharp, electricsharp, electricThrobbingThrobbing shooting, stabbingshooting, stabbing
Musculoskeletal PainMusculoskeletal Pain• SpasticitySpasticity
– ROM and stretching- involve family, ROM and stretching- involve family, therapists and nursingtherapists and nursing
– Modalities- ice, heatModalities- ice, heat– Renew current medsRenew current meds– Anti-spasticity meds- dantrolene, Anti-spasticity meds- dantrolene,
baclofen, tizanadinebaclofen, tizanadine– Botox, Nerve BlocksBotox, Nerve Blocks
• ContracturesContractures– Prevention is key! Range of MotionPrevention is key! Range of Motion– Serial Casting and Bracing/SplintsSerial Casting and Bracing/Splints
• SpasticitySpasticity– ROM and stretching- involve family, ROM and stretching- involve family,
therapists and nursingtherapists and nursing– Modalities- ice, heatModalities- ice, heat– Renew current medsRenew current meds– Anti-spasticity meds- dantrolene, Anti-spasticity meds- dantrolene,
baclofen, tizanadinebaclofen, tizanadine– Botox, Nerve BlocksBotox, Nerve Blocks
• ContracturesContractures– Prevention is key! Range of MotionPrevention is key! Range of Motion– Serial Casting and Bracing/SplintsSerial Casting and Bracing/Splints
Musculoskeletal PainMusculoskeletal Pain• Heterotopic Ossification (H.O.)- Heterotopic Ossification (H.O.)-
calcification of soft tissuescalcification of soft tissues– Elevated alkaline phosphataseElevated alkaline phosphatase– Bone scan for early diagnosis, plain Bone scan for early diagnosis, plain
films are positive once significant films are positive once significant calcification has occurredcalcification has occurred
– Indocin and Didronel Indocin and Didronel – Radiation therapy can also be usedRadiation therapy can also be used– Surgical Resection only when H.O. is Surgical Resection only when H.O. is
mature, usually after 18 monthsmature, usually after 18 months
• Heterotopic Ossification (H.O.)- Heterotopic Ossification (H.O.)- calcification of soft tissuescalcification of soft tissues– Elevated alkaline phosphataseElevated alkaline phosphatase– Bone scan for early diagnosis, plain Bone scan for early diagnosis, plain
films are positive once significant films are positive once significant calcification has occurredcalcification has occurred
– Indocin and Didronel Indocin and Didronel – Radiation therapy can also be usedRadiation therapy can also be used– Surgical Resection only when H.O. is Surgical Resection only when H.O. is
mature, usually after 18 monthsmature, usually after 18 months
Musculoskeletal PainMusculoskeletal Pain
• Fractures- missed diagnosisFractures- missed diagnosis
• Sprains/StrainsSprains/Strains
• Dislocation/SubluxationDislocation/Subluxation
• Impingement Impingement
• Skin- decubitis ulcers, etc.Skin- decubitis ulcers, etc.
• Stump painStump pain
• Fractures- missed diagnosisFractures- missed diagnosis
• Sprains/StrainsSprains/Strains
• Dislocation/SubluxationDislocation/Subluxation
• Impingement Impingement
• Skin- decubitis ulcers, etc.Skin- decubitis ulcers, etc.
• Stump painStump pain
Musculoskeletal Pain- TreatmentMusculoskeletal Pain- Treatment• Exercise, Range of Motion, MassageExercise, Range of Motion, Massage• Modalities- TENS, Ultrasound, Modalities- TENS, Ultrasound,
Heat, ColdHeat, Cold• Topical Medications- Capsaicin, etc.Topical Medications- Capsaicin, etc.• NSAIDSNSAIDS• Anti-spasticity meds- dantrolene, Anti-spasticity meds- dantrolene,
baclofen, tizanadinebaclofen, tizanadine• NarcoticsNarcotics• Acupunture, Chiropractic manipulationAcupunture, Chiropractic manipulation
• Exercise, Range of Motion, MassageExercise, Range of Motion, Massage• Modalities- TENS, Ultrasound, Modalities- TENS, Ultrasound,
Heat, ColdHeat, Cold• Topical Medications- Capsaicin, etc.Topical Medications- Capsaicin, etc.• NSAIDSNSAIDS• Anti-spasticity meds- dantrolene, Anti-spasticity meds- dantrolene,
baclofen, tizanadinebaclofen, tizanadine• NarcoticsNarcotics• Acupunture, Chiropractic manipulationAcupunture, Chiropractic manipulation
Neuropathic PainNeuropathic Pain
• Peripheral Nerve/Peripheral Nerve/Plexus InjuryPlexus Injury
• Complex Regional Pain Complex Regional Pain Syndrome/RSDSyndrome/RSD
• Central PainCentral Pain
• Phantom PainPhantom Pain
• Peripheral Nerve/Peripheral Nerve/Plexus InjuryPlexus Injury
• Complex Regional Pain Complex Regional Pain Syndrome/RSDSyndrome/RSD
• Central PainCentral Pain
• Phantom PainPhantom Pain
Neuropathic Pain- TreatmentNeuropathic Pain- Treatment• Most medications used for treatment of Most medications used for treatment of
Neuropathic pain do not have FDA Neuropathic pain do not have FDA approval for this use.approval for this use.
• AntidepressantsAntidepressants• Antiepileptic MedsAntiepileptic Meds• TENSTENS• Modalities-Contrast Baths, etcModalities-Contrast Baths, etc• Interventional Techniques- epidural Interventional Techniques- epidural
injections, sympathetic blocksinjections, sympathetic blocks
• Most medications used for treatment of Most medications used for treatment of Neuropathic pain do not have FDA Neuropathic pain do not have FDA approval for this use.approval for this use.
• AntidepressantsAntidepressants• Antiepileptic MedsAntiepileptic Meds• TENSTENS• Modalities-Contrast Baths, etcModalities-Contrast Baths, etc• Interventional Techniques- epidural Interventional Techniques- epidural
injections, sympathetic blocksinjections, sympathetic blocks
Pain due to BurnsPain due to Burns
• Initial Pain Management for Burns Initial Pain Management for Burns includes significant amount of includes significant amount of narcoticnarcotic
• During Rehab Phase monitor pain During Rehab Phase monitor pain level and function, attempt to level and function, attempt to minimize need for breakthrough minimize need for breakthrough pain medicationspain medications
• Initial Pain Management for Burns Initial Pain Management for Burns includes significant amount of includes significant amount of narcoticnarcotic
• During Rehab Phase monitor pain During Rehab Phase monitor pain level and function, attempt to level and function, attempt to minimize need for breakthrough minimize need for breakthrough pain medicationspain medications
“Other” Pain“Other” Pain
• Don’t blame pain on “the TBI”Don’t blame pain on “the TBI”
– Cardiac painCardiac pain
– Abdominal pathologyAbdominal pathology
• Review mechanism of event and Review mechanism of event and other injuries that occurred at the other injuries that occurred at the time of the initial event ie. time of the initial event ie. Abdominal trauma, etc.Abdominal trauma, etc.
• Don’t blame pain on “the TBI”Don’t blame pain on “the TBI”
– Cardiac painCardiac pain
– Abdominal pathologyAbdominal pathology
• Review mechanism of event and Review mechanism of event and other injuries that occurred at the other injuries that occurred at the time of the initial event ie. time of the initial event ie. Abdominal trauma, etc.Abdominal trauma, etc.
Pain Management GoalsPain Management Goals
• Improve Comfort AND FunctionImprove Comfort AND Function
• Correlate Pain Score with FunctionCorrelate Pain Score with Function
• Minimize Cognitive Side EffectsMinimize Cognitive Side Effects
• Avoid Poly-pharmacyAvoid Poly-pharmacy
• Assess and monitor effect of Assess and monitor effect of interventionintervention
• Involve the Patient and FamilyInvolve the Patient and Family
• Improve Comfort AND FunctionImprove Comfort AND Function
• Correlate Pain Score with FunctionCorrelate Pain Score with Function
• Minimize Cognitive Side EffectsMinimize Cognitive Side Effects
• Avoid Poly-pharmacyAvoid Poly-pharmacy
• Assess and monitor effect of Assess and monitor effect of interventionintervention
• Involve the Patient and FamilyInvolve the Patient and Family