Background & Aims

Nepalese Army Rehabilitation Centre was established in 2009 as the first Nepali government facility of its kind that caters to military personnel and civilians. In Nepal, landmines and other unexploded munitions from the last armed conflict continue to cause severe injuries and spinal cord injuries leading to paraplegia and quadriplegia. Till date the center has catered to 170 military and civilian personnel that have enabled the victims to resume living normal lives with independence and dignity. Pain is one of the major concerns among the residents and due to limitation in mobility cannot seek treatment from the chronic pain clinic of the tertiary military referral center (Shree Birendra Hospital – SBH) located 2 kilometers away. Hence pain management is provided by a multidisciplinary team including pain physician, physiotherapist and psychologist from the hospital on a weekly basis. This paper aims to study the prevalence of pain, access to care and efficacy of the treatment.

Methods

This is a retrospective study of 170 military and civilian patients admitted in the Nepal Army rehabilitation center since 2009. After obtaining ethical permission from the center, study was conducted among 155 males and 15 females via documentation and interview. The military personnel included veterans from the decade long insurgency as well as the service incurred disabilities. The duration of stay varied from less than 5 yrs (151), 5-10 yrs (13) and more than 10 yrs (6).The patients ranged from regular soldiers (65), retired army personnel (43), dependents (50) and civilian patients (12). This study was conducted to assess the injuries sustained, type and severity of pain, treatment modalities and efficacy of the treatment as indicated by regularity of visit and patient satisfaction. Numeric Rating Scale (NRS) of 0-10 was used to measure the severity of pain. The study was evaluated SPSS version 24 and the data was determined to be statistically significant if p value <0.05.

Results

Among the 170 residents of the rehabilitation center 49 were quadriplegic, 91 were paraplegic, 7 hemiparetic and 23 with others diagnoses. Prevalence of pain was found among 137 patients (80.58%). 99 (72.26%) patients reported musculoskeletal pain and 31 (22.62%) reported additional neuropathic pain. Among the musculoskeletal pain measurement ranged from moderate 85 patients (85.85 %) 14 severe (14.14%). Moderate pain was managed with NSAIDS, Baclofen and Pregabalin. Moderate to Severe pain was managed with oral tramadol and morphine. Severe intolerable pain patients were referred to a tertiary military hospital located within 2 kilometers from the center and were managed with opioid therapy – intravenous morphine and transdermal fentanyl citrate (TDFC) patches available on the strength of 25 and 50 micrograms per hour. Access to pain care was evaluated by regularity of visit and patient satisfaction regarding the multidisciplinary pain management protocol was found to be 84%.

Conclusions

Pain was a major concern among the patients with spinal cord injuries in a rehabilitation center in Nepal. Since patients had issue with mobility they could not avail the services from the pain clinic in the tertiary military hospital located nearby the center. Access to pain care was provided by a multidisciplinary pain management protocol to provide multimodal pain service to more than 80 % of the residents of the center with moderate to severe pain. A dedicated team of pain physician, physiotherapist and psychosocial counselor from SBH conducted weekly assessment and analgesic prescription. Follow up and routine care was provided by the duty nurses at the center. This protocol ensured continuum of pain care which significantly improved the quality of life of the residents. In conclusion access to pain care and patient satisfaction could be achieved by this very effective multidisciplinary pain management protocol in a rehabilitation center in a developing country.

References

1.Pain practice in Nepal thirty years ago: A practitioner’s Quest : Bal Bahadur Swar, DA: Journal of Society of Anesthesiologists Nepal JSAN 2017; 4(2):49-53.
2.Nepal: improving access to physical rehabilitation services: M Upadhyay 31-01-2011 News Release 11/23, ICRC Kathmandu.
3.Managing Pain in Low Resource Settings: Healthcare Professionals’ Knowledge, Attitude and Practice Regarding Pain Management in Western Nepal: Thapa P et al: J Pain Res. 2022; 15: 1587–1599.
4.Evolution of pain management services in Nepal; Shrestha A et al: Anesthesia, Pain & Intensive Care; https://www.apicareonline.com
5.Bhattarai B. Establishing pain service in Dharan Nepal: overcoming the inertia. JSAN. 2019; 6(1). DOI: 3126/jsan.v6i1.24099

Presenting Author

Sunita Panta

Poster Authors

Dr Sunita Panta

MD (Anaesthesiology)

Armed Forces Medical College, University of Pune, India

Lead Author

Topics

  • Access to Care