Review Article
Acute to chronic pain transition in extremity trauma: A narrative review for future preventive interventions (part 2)

https://doi.org/10.1016/j.ijotn.2016.04.001Get rights and content

Abstract

Background

The first part of this series of 2 articles revealed that chronic pain is an important issue post extremity trauma (ET) involving permanent biological transformations. Interventions aimed at preventing chronic pain in ET patients are therefore required.

Objective

To conduct a comprehensive analysis of literature on risk and protective factors for chronic pain post-ET to guide the development of relevant preventive interventions.

Methods

A narrative review of the literature was undertaken. Databases were searched to identify studies on chronic pain prognostic factors in ET patients.

Results

Demographic, injury-related and psychological factors were shown to either contribute to or limit acute to chronic pain transition. High-intensity acute pain hasconsistently been identified as an important chronic pain risk factor. Other significant documented risk factors include: female gender, older age, less than college education, lower limb injury, symptoms of anxiety and depression and pain catastrophizing. Pain self-efficacy and pain acceptance have been shown to protect individuals against chronic pain.

Conclusions

This narrative review highlights factors placing ET patients at higher risk of chronic pain or protecting them against this problem. Determining how these factors could be addressed in preventive interventions is the next step before undertaking their development.

Introduction

The majority of trauma patients suffer a limb injury (Canadian Institute for Health Information, 2013). This health problem can induce high-intensity, acute pain relating to associated osseous and soft-tissue involvement. In this regard, approximately 50% of ET patients report moderate to severe pain at hospital discharge (Archer et al, 2012, Williamson et al, 2009) which becomes chronic in up to 86% of cases (Clay et al, 2012, Rosenbloom et al, 2013).

Pain has several negative consequences. Initial poorly managed acute pain has been linked with undesirable outcomes, such as delayed mobilization and recovery as well as prolonged hospital length of stay (Kehlet et al, 2006, Morrison et al, 2003). Furthermore, chronic pain has been shown to cause psychological distress (Castillo et al, 2013, Gureje et al, 2008, Tsang et al, 2008) and moderate to severe disabilities (Archer et al, 2012, Castillo et al, 2006, Holmes et al, 2010, Vranceanu et al, 2014) as well as to considerably affect return to work (Clay et al, 2010, MacKenzie et al, 2006) with social costs several years post-injury (Ebel et al., 2004). Therefore, the development of nursing interventions aimed at preventing chronic pain is urgently needed.

Acute to chronic pain transition has been related to complex interplays between biopsychosocial risk factors and protective factors (Katz, Seltzer, 2009, Voscopoulos, Lema, 2010). In part 1 of this series of two articles, permanent biological transformations (i.e., peripheral and central sensitizations, genetic priming and emotional shift in the brain circuitry involved in nociception) contributing to the development of chronic pain were described. Poor psychological health has also been identified as being involved in acute to chronic pain transition post-ET. Many studies have focused on chronic pain risk and protective factors over the last 10 years. A narrative review of these studies was conducted as this type of review allows formation of a basis for the justification of future research in a specific area (Cronin et al., 2008). A comprehensive analysis of chronic pain risk and protective factors may further guide nurses in identifying individuals at higher risk of chronic pain. It could also provide these professionals with potential research directions for preventive interventions.

Section snippets

Methods

Narrative reviews aim to critique and summarize a body of literature and draw conclusions about the topic of interest (Baumeister, Leary, 1997, Cronin et al, 2008). Narrative reviews differ from systematic reviews. The objective of systematic reviews is to answer well-focused questions employing rigorous and explicit methods to identify, critically appraise, extract and analyze patients' data from primary research (Centre for Reviews and Dissemination, 2009). On the other hand, narrative

Results

In this section, findings from the literature review analysis related to the topic of chronic pain risk factors post-ET are presented. Since chronic pain protective factors have been less studied than chronic pain risk factors, findings from studies conducted in other populations than in ET patients are also described. Conclusions about chronic pain risk and protective factors were mainly based on recently published systematic reviews as well as on a few longitudinal and cross-sectional

Conclusions

In part 1 of this series of two articles, the issue of acute to chronic pain transition post-ET has been featured as well as the biological transformations leading to this process. Part 2 revealed that additional methodologically rigorous longitudinal studies could provide a more definite understanding of chronic pain prognostic factors post-ET. However, available evidence provides key information about the profile of patients who can be at risk for chronic pain and about factors that could be

Conflict of interest statement

The authors do not have any financial nor personal relationships with other people or organizations that could have inappropriately influenced (biased) the content of this paper.

Funding source

The first author received fellowships from the Canadian Institutes of Health Research (CIHR), Fonds de Recherche du Québec – Santé (FRQ-S), the Quebec Nursing Intervention Research Network (RRISIQ) and McGill University for her doctoral studies.

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