454
H. Devine et al.
Table IV. World Health Organization (WHO) pain ladder analgesic
use on intensive care unit (ICU) admission and at initial assessment
Patients at ICU
admission
WHO pain ladder level n (%) Patients at baseline
clinic visit
n (%)
No medication
Level 1
Level 2
Level 3 9 (19)
12 (25)
21 (45)
5 (11)
27 (57)
4 (9)
15 (32)
1 (2)
ladder) increasing from 2% (n = 1) to 11% (n = 5). Even
with the increase in the number and potency of pain
medications prescribed, two-thirds of patients still
reported a “new” chronic pain (Table IV).
Healthcare support
This study found that over a quarter of patients (26%,
n = 8) were already accessing physiotherapy treatment
prior to their initial InS:PIRE attendance and a further
29% (n = 9) required referral after assessment to a spe-
cialist physiotherapist in areas such as the shoulder or
back. A number of patients required referral to local
gym schemes (19%, n = 6) to increase fitness and body
strength, or onward referral to other services, such as
their primary care physician (19%, n = 6).
DISCUSSION
This is one of the first studies internationally to explore
pain intensity and interference in ICU survivors. Two-
thirds of patients in this study reported a “new” chronic
pain when attending an ICU follow-up programme.
This chronic pain was of “moderate” intensity and was
reported to be directly related to the ICU admission.
The shoulder was the single most affected joint in this
study, with almost two-fifths of patients reporting this
problem. No significant predictors for chronic pain
were found. Chronic pain resulted in a high level of
interference in patients’ daily activities after discharge
from the ICU, with “enjoyment of life” and “sleep”
being the most severely affected at initial programme
attendance. It was also found that patients who have
had an ICU admission frequently needed pain medi-
cation for a “new” chronic pain after discharge from
the ICU. Furthermore, there appeared to be a need for
more potent analgesics following discharge from the
ICU. Pain interference, but not pain severity, improved
over the 1-year period, with “enjoyment of life” and
“work” now being the most affected.
The incidence of chronic pain in this study is con-
sistent with a previous study in ICU survivors, which
highlighted that up to 73% of patients reported chronic
pain at 12 months post-ICU discharge (3). Similarly,
another study reported that 56% of patients had chronic
pain at 2 years post-discharge (25). This incidence of
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chronic pain is higher than the European population
norm, which suggests that that 20% of people live with
chronic pain (26). The incidence of shoulder pain in
this study is almost double that of findings in another
study which found that over 20% of patients had shoul-
der pain post-ICU (9). The shoulder is a vulnerable
joint; the strategies employed to move patients in the
ICU often depend on pressure being placed on this
joint. This may be a cause of this new pain; however,
more information and research in this area is required.
The literature suggests that the causes of chronic pain
post-ICU are multifactorial. The severity of patient’s
illness in the ICU necessitates certain procedures,
which often cause pain/discomfort and prolonged
periods of immobilization, in addition to the critical
illness process (7). No significant predictors for chronic
pain were found in this population. However, ensuring
early mobility and appropriate physical therapy within
the hospital setting may help prevent some of the issues
seen in this cohort of patients. At present the literature
has focussed on functional capacity as an outcome
measure for interventional rehabilitation research in
this area. Future research must also understand the
potential impact of these interventions for pain deve-
lopment in this group.
In relation to the requirement for analgesics, there
is a dearth of literature on the pharmacological mana-
gement of chronic pain in ICU survivors after hospital
discharge and the associated cost. This is probably due
to the lack of involvement of pharmacists in post-ICU
follow-up clinics (27). It is important that future studies
address this issue to ensure that patients are receiving
safe, effective care.
Strengths of this evaluation include its systematic
approach to assessing pain in critically ill patients at-
tending an ICU recovery programme. Furthermore,
this is one of the first studies to apply a standardized
tool to help understand analgesic requirements in this
population. However, this study has several limitations.
Pain interference, but not pain severity, improved over
time; this may be due to improved psychological status
and the development of coping strategies to manage
pain over time. It is unclear whether this improvement
is correlated with self-efficacy and the amelioration of
psychological problems, such as anxiety and depres-
sion. These data were not available for analysis in the
present evaluation, but future research should explore
psychological profiles with chronic pain. The definition
of chronic pain utilized in this study, was pain which
persisted for more 12 weeks. There are a number of
different definitions of chronic pain in the literature
and this may limited the scope of the findings of this
study. Furthermore, this study took place in a single
centre with a small population. ICU survivors are at