Pain following extremity injury: management, predictions and outcomes

Chronic pain patients often relate their pain onset to acute injury such as surgery or trauma, drawing attention to the need to prevent the transition from acute to chronic pain. This transition is still a complex and poorly understood developmental process. A range of factors has been associated with the persistence of pain. The PROTACT-study was initiated as a one year prospective follow-up study with the primary aim to determine prognostic factors involved in the transition from acute to chronic pain after extremity injury. This will give the ability to target high-risk patients in the emergency setting and to intervene on one or more of these factors thereby preventing the development of chronic pain. Secondary objectives were to describe the current state of pain management following extremity injury and to determine the consequences of extremity injury and developing chronic pain post-injury in terms of quality of life. At 6 months post-injury, 43.9% of the patients still had some degree of pain and 10.1% developed chronic pain, defined as persisting pain with a pain score ≥4 on the site of injury. Chronic pain affects patient’s quality of life. Six prognostic factors for the development of chronic pain were found, of which only pain severity in the acute phase and pain catastrophizing are potentially modifiable and thus useful to prevent chronic pain. This arises the question whether and how these findings can contribute to a better clinical outcome. To reduce inadequate pain relief in the ED, the implementation of a nurse-initiated pain protocol was studied. This implementation appears to lead to an increase of analgesic provision, a shorter time to analgesics and a higher (clinically relevant) pain relief in patients with acute pain following extremity injury. Despite improvements in pain management, the results reflected by the amount of patients discharged with moderate to severe pain showed that there is still room for improvement in pain management. Accurate pain assessment by nurses is crucial for effective pain management. Following extremity injury, nurses significantly under assessed patient’s pain.