Defense And Veterans Pain Rating Scale Research Articles

Multidimensional versus unidimensional pain scales for the assessment of analgesic requirement in the emergency department: a systematic review.

Pain is a multidimensional experience, potentially rendering unidimensional pain scales inappropriate for assessment. Prior research highlighted their inadequacy as reliable indicators of analgesic requirement. This systematic review aimed to compare multidimensional with unidimensional pain scales in assessing analgesic requirements in the emergency department (ED). Embase, Medline, CINAHL, and PubMed Central were searched to identify ED studies utilizing both unidimensional and multidimensional pain scales. Primary outcome was desire for analgesia. Secondary outcomes were amount of administered analgesia and patient satisfaction. Two independent reviewers screened, assessed quality, and extracted data of eligible studies. We assessed risk of bias with the ROBINS-I tool and provide a descriptive summary. Out of 845 publications, none met primary outcome criteria. Three studies analyzed secondary outcomes. One study compared the multidimensional Defense and Veterans Pain Rating Scale (DVPRS) to the unidimensional Numerical Rating Scale (NRS) for opioid administration. DVPRS identified more patients with moderate instead of severe pain compared to the NRS. Therefore, the DVPRS might lead to a potential reduction in opioid administration for individuals who do not require it. Two studies assessing patient satisfaction favored the short forms (SF) of the Brief Pain Inventory (BPI) and McGill Pain Questionnaire (MPQ) over the Visual Analogue Scale (VAS) and the NRS. Limited heterogenous literature suggests that in the ED, a multidimensional pain scale (DVPRS), may better discriminate moderate and severe pain compared to a unidimensional pain scale (NRS). This potentially impacts analgesia, particularly when analgesic interventions rely on pain scores. Patients might prefer multidimensional pain scales (BPI-SF, MPQ-SF) over NRS or VAS for assessing their pain experience.

Single port robot-assisted pyeloplasty: An early comparative outcomes analysis.

The treatment paradigm for ureteropelvic junction obstruction (UPJO) has shifted towards minimally invasive pyeloplasty. A comparison Single Port (SP) and Multi Port (MP) robot-assisted pyeloplasty (RAP) was performed. Data from consecutive patients undergoing SP RAP or MP RAP between January 2021 and September 2023 were collected and analysed. Co-primary outcomes were length of stay (LOS), Defense and Veterans Pain Rating Scale (DVPRS), and narcotic dose. The choice of the robotic system depended on the surgeon's preference and availability of a specific robotic platform. A total of 10 SP RAPs and 12 MP RAPs were identified. SP RAP patients were significantly younger [23years (20-34)] than MP RAP [42years (35.5-47.5), p<0.01]. No difference in terms of OT (p=0.6), LOS (p=0.1), DVPRS (p=0.2) and narcotic dose (p=0.1) between the two groups was observed. SP RAP can be implemented without compromising surgical outcomes and potentially offering some clinical advantages.

A Study to Assess the Efficacy of Ultrasound-guided Bilateral Erector Spinae Plane Block for Total Abdominal Hysterectomy under Spinal Anesthesia: A Prospective Randomized Control Study

Abstract Background: Postoperative discomfort after a total abdominal hysterectomy (TAH) is severe. The Erector spinae plane block (ESPB) is the latest addition to the multimodal pain management regimen, providing both visceral and somatic analgesia. Aim: The aim of this study was assessed the postoperative analgesic efficacy of ultrasound-guided bilateral ESPB for TAH. Materials and Methods: 70 female patients aged 40 to 60 years, American society of anaesthesiology (ASA) physical status class I and II posted for TAH were enrolled. Group ESPB+SA(n=35) received bilateral ESPB using 0.25% ropivacaine hydrochloride 15ml with 0.5µ/kg dexmedetomidine on each side before spinal anaesthesia, while group SA (n=35) received only spinal anaesthesia. Postoperative follow-up for 24 hours.Statistical analysis used: Independent-samples student t-test. Results: The total dose of tramadol injection consumed in the first 24 hours postoperatively in group ESPB+SA was significantly low (110.34mg) as compared to group SA (334.29mg) (P &lt; 0.001). Time for first rescue analgesia was prolonged significantly in group ESPB+SA while it was very short in Group SA(P &lt; 0.001). Postoperatively the mean modified defense and veterans pain rating scale (DVPRS) for pain was lower in group ESPB+SA than in group SA, and the difference was statistically significant (P &lt; 0.001). Similarly, scores for other modified DVPRS components, such as sleep, activity, mood and stress were lower in the ESPB+SA group. Conclusions: Bilateral ultrasound-guided ESPB prior to spinal anaesthesia offers effective and prolonged postoperative analgesia, with significantly lower postoperative tramadol use and a higher satisfaction score in patients undergoing TAH under spinal anaesthesia.

The Use and Perceptions of the Defense and Veterans Pain Rating Scale by Nursing Personnel

BackgroundIn 2010, the Office of the US Army Surgeon General recommended the Veterans Administration (VA) assess pain using the Defense and Veterans Pain Rating Scale (DVPRS). One item in the DVPRS is for measuring pain intensity. This item contains a combination of five response metrics: categories, faces, colors, numbers, and functional descriptors. A few studies have supported patients’ and health care providers’ preferences for the DVPRS and its psychometric properties. However, they also left uncertainties about its usability and validity. AimsTo advance our understanding of the DVPRS, this study examined the use and perceptions of the DVPRS’ pain intensity item by nursing personnel during multi-modal care. DesignA cross-sectional survey design was used. SettingVA Community Living Center. ParticipantsNursing personnel. MethodsNursing personnel answered closed- and open-ended survey questions during a single session. ResultsNursing personnel reported sufficient training before implementing the measure and that patients primarily used the numeric metric. When patients used a non-numeric metric, the nursing personnel responded in variable ways. In addition, the nursing personnel interpreted the functional descriptors differently. The nursing personnel also noted the need to supplement the pain intensity item with patients’ pain duration and pain location. ConclusionsResults from this study inform the nursing community about the DVPRS’ pain intensity item, which combines multiple response metrics. The results support the need for nursing units to generate and standardize procedures for using the item to measure multi-site pain and for interpreting and documenting patients’ non-numeric responses. The effects of such procedures on the measure's usability and psychometric properties warrants additional investigation.

Validity of the Modified Defense and Veterans Pain Rating Scale Supplemented With Items Germane to Total Joint Replacement: Secondary Analysis From a Randomized Trial.

Valid measures of pain are helpful to adjust treatment plans in real time after total joint replacement (TJR). We enhanced the existing Defense and Veterans Pain Rating Scale (DVPRS) with items related to pain at rest and movement, in specific reference to operative and nonoperative joints, creating the TJR-DVPRS. This manuscript is presented to validate the modified survey instrument. The aims of this psychometric study were to evaluate (1) the latent structure of the TJR-DVPRS, (2) the relationships among the pain dimensions represented on the TJR-DVPRS and the reference-standard Short-Form McGill Pain Questionnaire (version 2, SF-MPQ-2), and (3) the responsiveness of these two measures before and after TJR. This report involves a secondary analysis of pain surveys from 135 veterans undergoing TJR at one center who participated in a randomized trial. The study was approved by the institutional review boards from participating institutions. The TJR-DVPRS and SF-MPQ-2 were completed preoperatively, during postoperative day 1, and 6 weeks post-surgery. Standard psychometric evaluations included correlations, principal component analysis, and internal consistency of survey items and subscales, using preoperative baseline data as a frame of reference. Responsiveness analysis included assessing both effect size and thresholds of clinically important change for survey subscales using data from all three time points. Two reliable subscales were identified for the TJR-DVPRS, one including items about pain intensity and interference related to the operative joint (Cronbach's α = .809) and the other including two pain items on the nonoperative joint. Combining the subscales indicated a two-factor solution: The first valid factor entailed the four subscales of the SF-MPQ-2 and the TJR-DVPRS operative joint subscales, indicating that these subscales validly represent the same pain dimension. The second valid factor entailed the TJR-DVPRS subscale addressing the nonoperative joint. Responsiveness analysis following accepted psychometric methods demonstrated significant decreases in pain from the preoperative period to 6 weeks postoperatively for all subscales. The TJR-DVPRS and SF-MPQ-2 subscales were similarly responsive, except for the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales, which were minimally responsive during the preoperative to 6-week period. The TJR-DVPRS is valid for use among veterans undergoing TJR and poses significantly less respondent burden than does the SF-MPQ-2. The brevity and ease of use of the TJR-DVPRS make it a practical tool for use during surgical recovery to monitor pain intensity at rest and with movement in the operative joint, and to assess pain interference with activity, sleep, and mood. The TJR-DVPRS is at least as responsive as the SF-MPQ-2, but the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales were minimally responsive. Limitations of this study include the small sample size, under-representation of women (which would be expected in the veteran population), and using only veterans. Future validations studies should include civilians and active military TJR patients.

MP15-07 UROLOGIC CHRONIC PELVIC PAIN ASSESSMENT USING THE NUMERIC RATING SCALE AND DEFENSE VETERANS RATING SCALE

You have accessJournal of UrologyCME1 Apr 2023MP15-07 UROLOGIC CHRONIC PELVIC PAIN ASSESSMENT USING THE NUMERIC RATING SCALE AND DEFENSE VETERANS RATING SCALE William Shyr, Kelli Aibel, Eric Macdonald, Karen Huang, and Robert Moldwin William ShyrWilliam Shyr More articles by this author , Kelli AibelKelli Aibel More articles by this author , Eric MacdonaldEric Macdonald More articles by this author , Karen HuangKaren Huang More articles by this author , and Robert MoldwinRobert Moldwin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003235.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pain scores are essential tools used to assess urologic chronic pelvic pain (UCPP). The Numeric Rating Scale (NRS) rates pain on a 0-10 numeric scale. The Defense and Veterans Pain Rating Scale (DVPRS) is a newly designed and validated pain scale that improves upon the NRS by incorporating faces, color-coded bars, and quality-of-life (QoL) descriptors that correspond to each pain level from 0-10. To our knowledge, the use of DVPRS in patients with UCPP has not been described within the literature. We studied the relationship between the NRS and DVPRS in patients with UCPP. METHODS: We retrospectively reviewed the charts of 107 patients with UCPP, including interstitial cystitis, bladder pain syndrome, pelvic floor myalgia, vulvodynia, and chronic prostatitis/chronic pelvic pain syndrome. Patients completed validated survey instruments, including the NRS, DVPRS, and pain catastrophizing score (PCS). The NRS and DVPRS were correlated using the Spearman correlation coefficient. The Wilcoxon signed-rank test was used to analyze the differences between the pain scales. We also analyzed pain levels in relation to sociodemographic data and comorbidities, such as back pain, fibromyalgia, anxiety, and depression. RESULTS: The median patient age was 58. The NRS and DVPRS were positively correlated with each other (R=0.77; p<0.001) (Figure 1). Both scales were negatively correlated with age, but the association was not significant (NRS: R=–0.10, p=0.30; DVPRS: R=–0.14, p=0.13). The differences in pain scores, defined as NRS minus DVPRS, ranged from -4 to 5, with one potential outlier of 5. However, the Wilcoxon signed-rank test showed no significant differences in pain scores across the two scales (p=0.57). When pain level was categorized into low (0-3), moderate (4-7), and high (8-10), the NRS and DVPRS had no significant associations with pain severity, sex, and comorbidities. CONCLUSIONS: Our findings demonstrated that both scales are strongly correlated with no significant differences. Given that the DVPRS relates each pain level to QoL measures, our study suggests that UCPP patients likely take their QoL into account when rating their pain levels on the NRS. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e194 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information William Shyr More articles by this author Kelli Aibel More articles by this author Eric Macdonald More articles by this author Karen Huang More articles by this author Robert Moldwin More articles by this author Expand All Advertisement PDF downloadLoading ...

Patterns of Change in Pain-related Physical, Mental, and Social Health Outcomes in a Military Population

Objective: Military persons frequently experience pain conditions stemming from noncombat and combat injuries. This study assessed the patterns of change over time and the associations of pain intensity and interference with physical, mental, and social health domains in a military sample.Methods: A secondary analysis of Pain Assessment Screening Tool and Outcomes Registry (PASTOR) was conducted using data collected over 10 months. Participants selected for analysis completed ≥3 assessments with an interval of ≥14 days between assessments. The Defense and Veterans Pain Rating Scale (DVPRS) measured average and worst pain intensity, and Patient-Reported Outcomes Measurement Information System (PROMIS®) T-scores measured pain and health outcomes.Results: The sample (N = 190) majority reported being active duty (96%); serving in the U.S. Army (93%); and being enlisted (86%). The percent difference from assessment one to assessment three showed improvement for DVPRS average pain (–4.85%) and worst pain(–2.16%), and PROMIS Pain Interference T-score (–1.98%). Improvements were observed for all PROMIS outcomes except depression. The Defense and Veterans Pain Rating Scale average and worst pain intensity and PROMIS pain interference were strongly correlated with physical function. Multilevel models showed that an increase in average and worst pain, and pain interference were associated with a decrease in satisfaction with social roles.Conclusion: Analysis identified patterns of change over time in physical, mental, and social health outcomes, as well as associations important to understanding the complexities of pain. This work has implications for pain management nursing in ambulatory settings where ongoing collection and analyses of multivariable outcomes data can inform clinical care.

All MCIDs Are Wrong, But Some May be Useful.

To demonstrate how to apply a baseline-adjusted receiver operator characteristic curve (AROC) analysis for minimum clinically important differences (MCIDs) in an empirical data set and discuss new insights relating to MCIDs. Retrospective study. This study includes data from 999 active-duty military service patients enrolled in the United States Military Health System's Military Orthopedics Tracking Injuries and Outcomes Network. Anchored MCIDs were calculated using the standard receiver operator characteristic analysis and the AROC analysis for the Patient-Reported Outcome Measure Information System (PROMIS) Pain Interference and Defense and Veterans Pain Rating Scale (DVPRS). Point estimates where confidence intervals (CIs) crossed the 0.5 identity line on the area-under-the-curve (AUC) analysis were considered statistically invalid. MCID estimates where CIs crossed 0 were considered theoretically invalid. In applying an AROC analysis, the region of AUC and MCID validity for the PROMIS Pain Interference score exists when the baseline score is greater than 61.0 but less than 72.3. For DVPRS, the region of MCID validity is when the baseline score is greater than 5.9 but less than 7.9. Baseline values influence not only the MCID but also the accuracy of the MCID. MCIDs are statistically and theoretically valid for only a discrete range of baseline scores. Our findings suggest that the MCID may be too flawed a construct to accurately benchmark treatment outcomes. J Orthop Sports Phys Ther 2022;52(6):401-407. doi:10.2519/jospt.2022.11193.

Topical Morphine Gel as a Systemic Opioid Sparing Technique

Use of topical morphine gel was explored retrospectively for treatment of painful chronic wounds in hospitalized adults. Systemic opioid use and pain intensity were characterized before and after morphine gel initiation using morphine equivalent daily dose (MEDD) and the Defense and Veterans Pain Rating Scale (DVPRS) score at 24 hours before compared to 24 hours, 48 hours, and one week after morphine gel initiation. Twenty-three patients received 371 applications of topical morphine gel. The median number of applications received was 8.0 [5.0 to 26.0] per patient. Median change in MEDD 24 hours after morphine gel initiation was 0.0 mg [−15.3 to 11.3] (n = 21), 48 hours after was −4.4 mg [−27.5 to 8.8] (n = 20), and one week after was −7.5 mg [−41.9 to −0.3] (n = 12). Median change in DVPRS score 24 hours after morphine gel initiation was 0.0 [−0.5 to 1.5] (n = 13), 48 hours after was −0.5 [−3.25 to 0.0] (n = 14), and one week after was 1.0 [−1.0 to 3.5] (n = 9). In this single-center analysis, patients with painful chronic wounds treated with morphine gel required lower doses of systemic opioids. Topical morphine gel may provide analgesia while sparing systemic opioid use.

Concurrent Validity of PROMIS With DASH and DVPRS in Transhumeral Amputees.

We sought to assess whether select domains of the Patient-Reported Outcomes Measurement Information System (PROMIS) significantly correlate with the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Defense and Veterans Pain Rating Scale (DVPRS) among transhumeral amputees. We prospectively administered DASH, DVPRS, and PROMIS (including Upper Extremity, Pain Interference, and Pain Behavior domains) testing to patients presenting for consideration of osseointegration after transhumeral amputation. Concurrent validity was assessed via Pearson correlation testing. The mean DASH score of the cohort was 32.8. The mean DVPRS score was 1.8. The mean PROMIS scores were 33.8, 50.5, and 50.6 for Upper Extremity, Pain Interference, and Pain Behavior domains, respectively. Pearson testing demonstrated a significant, inverse correlation between DASH and PROMIS Upper Extremity scores (r = -0.85, P = .002). There was also significant correlation between DVPRS and PROMIS Pain Interference scores (r = 0.69, P = .03). The PROMIS Pain Behavior domain did not significantly correlate with either DASH or DVPRS. Patient-Reported Outcomes Measurement Information System Upper Extremity and Pain Interference scores demonstrated significant concurrent validity with traditional measures (DASH and DVPRS) of patient-reported outcome in our population of transhumeral amputees.

Comparing Pain Intensity Using the Numeric Rating Scale and Defense and Veterans Pain Rating Scale in Patients Revisiting the Emergency Department.

Objective To determine the relationship between Numeric Rating Scale (NRS) and Defense and Veterans Pain Rating Scale (DVPRS) as pain intensity measures, we compared pain scores to sociodemographic and treatment data in patients revisiting the emergency department (ED).Methods After Institutional Review Board approval, 389 adults presenting within 30 days of an index visit were enrolled. Pain scores were classified as follows: 0-3 (mild), 4-7 (moderate), and 8-10 (high). Data were analyzed using descriptive analysis. Wilcoxon rank-sum test measured the association of pain score with gender. Pain scales were correlated using Spearman correlation coefficient. Pain scale association with opioid treatment was tested via ordinal logistic regression controlling for gender, home opioid use, and if ED revisit was for pain.Results Average patient age was 49. Most patients were African American (68.4%), male (51.2%), and returned for pain (67.0%). As continuous measures, both scales were positively correlated with each other (p<0.0001). Pain score severity categories were distributed differently between the two scales (p=0.0085), decreasing by 8% in patients reporting high pain severity when using DVPRS. For both scales, the proportion of patients (1) administered opioids (p=0.0009 and p≤0.0001, respectively) and (2) discharged with opioids (p=0.0103 and p=0.0417, respectively) increased with pain severity. Discharge NRS (p=0.0001) (OR=3.2, 1.780-5.988) and DVPRS pain score categories (p<0.0001) (OR=2.7, 95% CI=1.63-4.473) were associated with revisits for pain. ConclusionsOur findings demonstrate a link between NRS and administration of opioid medications and suggest that DVPRS may better differentiate between moderate and high levels of pain in the ED setting.

586 Patient Satisfaction for the Use of DVPRS in the Assessment of Pain in the Burn and Surgical ICU

Abstract Introduction The assessment and treatment of pain has become increasingly important in light of the opioid epidemic. Inadequately managed pain can lead to increased risk of psychiatric illness. The numeric rating scale (NRS) is used in most ICUs and only assesses pain intensity. Although it is reliable, valid, and user-friendly, other publications have criticized this one-dimensional pain assessment tools as offering little information about the impact of the pain on the patient’s life. The defense and veterans pain rating scale (DVPRS) is a multi-dimensional tool designed to assess the patient’s pain intensity as well as how the pain interferes with the patient’s general activity, sleep, mood and stress. Studies have shown that it has good validity and reliability in the inpatient and outpatient military population with neuropathic and non-neuropathic pain. The DVPRS has not been evaluated in critical care patients. Thus, this study comparatively investigated ICU patients’ satisfaction with the DVPRS versus the NRS. Methods This was a prospective pilot study performed from September 2018 to July 2019 in a 10 bed burn intensive care unit (BICU) and 10 bed surgical intensive care unit (SICU) at a university teaching hospital. This was an IRB approved study. All enrolled patients were older than 18 years of age and were CAM-ICU negative. The participating staff members were educated on the use of the scales prior to the start of the study. Routine treatment of pain was not altered by the study. Pain was assessed by staff nurses randomly assigned to use the NRS or DVPRS tool. The selected tool was used on admission, during wound care and every 4 hours or upon patient need. The patients completed satisfaction surveys on the day of discharge. Results 42 patients participated and 32 completed the study. 18 patients were in the DVPRS arm and 14 were in the NRS arm. Our primary outcome was patient satisfaction, ranked on a scale from 0–10, where 0 was the lowest score and 10 was the highest. Overall, patients in the DVPRS cohort had higher median satisfaction scores (median score: 10, interquartile range: 8–10) than the NRS cohort (median score: 8, interquartile range 7–9), though this difference did not reach statistical significance (p=0.16). However, DVPRS patients were significantly more likely to be “completely satisfied” than NRS patients (55.6% in DVPRS patients versus 21.4% in NRS patients; p=0.04). Furthermore, upon multivariate logistic analysis adjusting for age, gender, and ICU using the NRS pain scale conferred lower odds of complete satisfaction with pain management (odds ratio: 0.19, p=0.04). Conclusions Our study showed that ICU patients preferred the DVPRS over the NRS. The DVPRS appeared to be as effective as the NRS in pain relief and gave providers more information about patients’ pain.

Sublingual Buprenorphine/Naloxone and Multi-Modal Management for High-Risk Chronic Pain Patients.

Patients with chronic pain managed with opioid medications are at high risk for opioid overuse or misuse. West Virginia University (WVU) established a High-Risk Pain Clinic to use sublingual buprenorphine/naloxone (bup/nal) plus a multimodal approach to help chronic pain patients with history of Substance Use Disorder (SUD) or aberrant drug-related behavior. The objective of this study was to report overall retention rates and indicators of efficacy in pain control from approximately six years of High-Risk Pain Clinic data. A retrospective chart review was conducted for a total of 78 patients who enrolled in the High-Risk Pain Clinic between 2014 and 2020. Data gathered include psychiatric diagnoses, prescribed medications, pain score, buprenorphine/naloxone dosing, time in clinic, and reason for dismissal. A linear mixed effects model was used to assess the pain score from the Defense and Veterans Pain Rating Scale (DVPRS) and daily bup/nal dose across time. The overall retention of the High-Risk Pain Clinic was 41%. The mean pain score demonstrated a significant downward trend across treatment time (p < 0.001), while the opposite trend was seen with buprenorphine dose (p < 0.001). With the benefit of six years of observation, this study supports buprenorphine/naloxone as a safe and efficacious component of comprehensive chronic pain treatment in patients with SUD or high-risk of opioid overuse or misuse.

Predicting Treatment Success with Facet Syndrome: An Algorithm to Predict Lumbar Radiofrequency Ablation Responders in a Military Population.

Radiofrequency ablation (RFA) of the medial branch nerve is a commonly performed procedure for patients with facet syndrome. RFA has previously been demonstrated to provide long-term functional improvement in approximately 50% of patients, including those who had significant pain relief after diagnostic medial branch block. We sought to identify factors associated with success of RFA for facet pain. Active-duty military patients who underwent lumbar RFA (L3, L4, and L5 levels) over a 3-year period were analyzed. Defense and Veterans Pain Rating Scale (DVPRS) and Oswestry Disability Index (ODI) scores were assessed the day of procedure and at the 2-month and 6-month follow-up. These data were analyzed to identify associations between patient demographics, pain, and functional status and patients' improvement after RFA, with a primary outcome of ODI improvement and a secondary outcome of pain reduction. Higher levels of starting functional impairment (starting ODI scores of 42.9 vs. 37.5; P = 0.0304) were associated with a greater likelihood of improvement in functional status 6 months after RFA, and higher starting pain scores (DVPRS pain scores of 6.1 vs. 5.1; P < 0.0001) were associated with a higher likelihood that pain scores would improve 6 months after RFA. A multivariate logistic regression was then used to develop a scoring system to predict improvement after RFA. The scoring system generated a C-statistic of 0.764, with starting ODI, pain scores, and both gender and smoking history as independent variables. This algorithm compares favorably to that of diagnostic medial branch block in terms of prediction accuracy (C-statistic of 0.764 vs. 0.57), suggesting that its use may improve patient selection in patients who undergo RFA for facet syndrome.

A Longitudinal Comparison of Patient-Reported Outcomes Measurement Information System to Legacy Scales in Knee and Shoulder Arthroscopy Patients

The purpose of this prospective correlational study was to compare the psychometric properties of the Defense and Veterans Pain Rating Scale (DVPRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scales with those of traditional legacy scales over a longitudinal postoperative period in patients undergoing arthroscopic procedures. Active-duty military personnel undergoing shoulder and knee arthroscopic procedures completed the DVPRS, PROMIS, and legacy scales preoperatively and again at 3 months postoperatively. Rolling correlation coefficients (rrm) were used to assess the concurrent validity between the DVPRS average pain scores and computer adaptive testing PROMIS scales (Anxiety, Depression, Pain Behavior, Pain Interference, Mobility, Sleep Disturbance, Satisfaction With Social Roles, and Upper Extremity Physical Function) and the legacy scales (American Shoulder and Elbow Surgeons [ASES] scale, Shoulder Activity Scale, International Knee Documentation Committee [IKDC] questionnaire, Single Assessment Numeric Evaluation [SANE], Marx Activity Rating Scale, and Veterans RAND 12-Item Health Survey). A total of 121 participants completed the scales preoperatively, 80 completed them at 3months postoperatively, and 59 (49% of participants) completed them at both times. Rolling correlation coefficients between PROMIS Pain Interference (rrm= -0.41, P= .006), Satisfaction With Social Roles (rrm= 0.56, P < .001), and Upper Extremity (rrm=0.71, P < .001) scores showed acceptable concurrent validity with ASES scores over a longitudinal postoperative period. DVPRS scores (rrm= -0.69, P= .002) and PROMIS Pain Behavior (rrm= -0.57, P= .018), Pain Interference (rrm= -0.71, P= .001), Sleep Disturbance (rrm= -0.64, P= .005), and Mobility (rrm= 0.65, P= .005) scores showed acceptable concurrent validity with IKDC scores. There was poor correlation between the PROMIS and DVPRS scores and the Single Assessment Numeric Evaluation, Marx Activity Rating Scale, Shoulder Activity Scale, and Veterans RAND 12-Item Health Survey scores. PROMIS scales measuring physical function, pain presentation, and other health domains showed acceptable concurrent validity with ASES and IKDC scores. By integrating the prospective collection of biopsychosocial PROMIS scales into practice, it is possible for clinicians in orthopaedic settings to assess changes in validated patient-reported outcomes to inform patient-centered care planning throughout the postoperative recovery period. Level II, prospective comparative study (with not all participants completing follow-up).

Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction.

No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS). In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge. The mean MED administered postoperatively was lower in the ERAS group (17.6mg) than in the control group (65.0mg) (p<.001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p=.042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p<.001). The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.

Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq.

The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha=0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

Fascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial

To determine in a prospective, randomized fashion whether liposomal bupivacaine extends the effectiveness of decreased pain scores and reduces narcotic requirements following hip arthroscopy when used in addition to a fascia iliaca blockade with plain bupivacaine alone. Double-blinded prospective randomized controlled trial of participants undergoing hip arthroscopy. Randomized to receive a fascia iliaca blockade with 40mL 0.25% plain bupivacaine (100mg; control group) or 20mL 0.5% plain bupivacaine (100mg) plus 20mL liposomal bupivacaine (266mg; study group). The primary outcome was Defense and Veterans Pain Rating Scale (DVPRS) scores in the postanesthesia care unit and on postoperative days (POD) 1, 2, 3, and 14. Secondary outcomes included postoperative opioid consumption and subjective loss of anterior thigh sensation. Seventy-four patients were enrolled, and 70 completed the study; 37 were randomized to the control group and 33 to the study group. There was no significant difference in postoperative DVPRS scores at any time point. There was no significant difference in total postoperative opioid use during any postoperative time points. While most patients reported anterior thigh numbness at discharge, significantly more patients in the study group reported anterior thigh numbness at POD2 (control, 19/37 numb vs study, 32/33 numb; P < .0001) and at POD3 (control, 8/37 numb vs study, 26/33 numb; P < .0001). In this prospective evaluation comparing plain bupivacaine versus the liposomal formulation administered via a fascia iliaca blockade there were no significant differences in postoperative pain scores and narcotic pill usage. Given the highly significant findings of prolonged anterior thigh numbness out to POD3 in patients who received liposomal bupivacaine, this formulation did exhibit prolonged effects; however, it did not provide improved pain control when used in this surgical population, likely due to the innervation of the hip capsule from differential nerve plexi. Given the 6-fold increased cost of using the liposomal formulation, we are unable to recommend its use via a fascia iliaca blockade for hip arthroscopy. Level I, therapeutic study.

(150) Short-Term Outcomes following an Intensive Outpatient Program for Patients with Comorbid Substance Use Disorder and Chronic Pain at Walter Reed National Military Medical Center (WRNMMC)

Research suggests a high comorbidity between chronic pain and substance use disorder (SUD), particularly within a military population. Optimal clinical treatment for those with chronic pain and SUD is believed to be multidisciplinary care. However, limited research has been conducted on this topic within the military health care system (MHS). This quality improvement project examines short-term outcomes for a joint-SUD and chronic pain intensive outpatient program (IOP). Active duty, veterans, and dependents were enrolled in a 6-week Joint-IOP at WRNMMC. The multidisciplinary team included addiction social workers, physical therapists, nurses, and clinical psychologists. Patients received a breathalyzer and urine drug screen at the time of treatment initiation and periodically throughout. Participants filled out the following validated questionnaires pre- and post-treatment: Defense and Veterans Pain Rating Scale (DVPRS), Pain Outcomes Questionnaire (POQ), Brief Addiction Monitor (BAM), World Health Organization Quality of Life-Brief (WHOQOL-BREF) and Pain Catastrophizing Scale (PCS). Fifty-eight patients completed the joint-IOP. Paired T-tests suggest a reduction in DVPRS worst pain scores (p=0.013), reduced POQ total impairment (p=0.034) and improved POQ vitality (p=0.024) from pre- to post-treatment. Paired T-tests suggest a trend toward decreased alcohol and substance use as measured by the BAM (p=0.056). Both WHO quality of life and pain catastrophizing showed no significant change. This project suggests that patients suffering from chronic pain and SUD within the MHS have improved pain and SUD outcomes at the completion of a 6-week joint-IOP. Implications of this project suggest the importance of concurrently treating chronic pain and SUD within the MHS.

Abstract PD6-03: Pilot project assessing the impact of self-care techniques on post-surgical pain, fatigue, and inflammation

Abstract More than one third of women diagnosed with breast cancer experience significant emotional distress, which may then effect pain perception, wound healing, quality of life (QOL), and return to physical function. Several studies have shown that physical and cognitive relaxation strategies may relieve perioperative anxiety, leading to improved postoperative pain and QOL. One hundred women from Brooke Army Medical Center with non-metastatic breast cancer, planning to undergo surgery as initial treatment, were randomly assigned using an intention-to-treat model to either the treatment as usual group (TAU; n = 49) or TAU plus a self-care toolkit (SCT; n=51). The SCT included audio-recordings of guided mind-body techniques (breathing, progressive muscle relaxation, meditation, guided imagery, and self-hypnosis), an acupressure anti-nausea wristband, and a workbook with instructions for use of the tools plus a section to journal the cancer experience. Pain, anxiety, nausea, sleep, fatigue, global health, and QOL were assessed using the Defense and Veterans Pain Rating Scale (DVPRS), the 10-cm Visual Analog Scale (VAS), and the NIH PROMIS-57 subscales. Data was collected at baseline (T1), immediately prior to surgery (T2), within 10 hours post-operatively (T3), and approximately two weeks post-surgery (T4). Two inflammatory blood markers (ESR and CRP) were measured at T1, T2, and T4. Due to diurnal variability of ESR and CRP, laboratory draws were generally collected prior to 10:00 AM. Categorical variables and frequency counts were analyzed using Chi-Squared or Fisher's Exact tests, whichever was most appropriate. Means and standard deviations were used as summary statistics for continuous variables and analyzed using Student's t-test, ANOVA, and/or Wilcoxon's Test. For data measured at two time points, the delta change in values was calculated to detect within-group differences in SCT and TAU using Wilcoxon's rank sum test or paired t-test. For factors measured at more than two time points, a two-way repeated measures ANOVA was implemented with a Bonferroni corrected post-hoc analysis to determine between-group differences at each time point. Between T1 and T4, there were significant between group differences in PROMIS-57 scores of Pain Interference, Fatigue, and Satisfaction With Social Roles, favoring the SCT group compared to TAU (p=0.005, p=0.023, and p=0.021, respectively). There was a significant mean change in DVPRS scores from T2 to T3, with the SCT group having significantly smaller increases in post-operative pain (p=0.008) and in post-operative ESR (p=0.0197) compared with the TAU group. Clinically significant reductions in anxiety occurred in the SCT group during the main intervention period. These results suggest that using the SCT in the perioperative period decreased pain perceptions, fatigue, and inflammatory cytokine secretion. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force and Department of Defense or the U.S. Government. Citation Format: Setlik RF, Inman A, Peacock K, Aden J, Paat C, Stoerkel E, Bellanti D, Walter J. Pilot project assessing the impact of self-care techniques on post-surgical pain, fatigue, and inflammation [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-03.