Managing Chronic Pain in Individuals with Brain Injury

1. Managing Chronic Pain in Individuals with Brain Injury Kenneth R Britton, DO MMM Britton Pain Clinic St. Paul, MN

2. Introduction • Interaction with the audience, including: • Who I am • Who the audience is • What does the audience want to discuss about pain and TBI

3. Disclosures • I have no financial disclosures to make • I do have biases • I’m old school and think the physician should lead the team • I think people with TBI are more likely than not to experience a lot of symptoms • I think that individuals and family are likely to make too much fuss about mild symptoms BUT • I also think that as health care providers we dismiss common symptoms that can be improved, especially when we see the issues as too complex or too messy, which usually means that I don’t understand them well enough to be confident in my ability to address them

4. Definitions—making sure we are speaking the same language • TBI • Mild • Moderate/severe • Pain • Duration—acute vs chronic • Severity—mild (1-3/10), moderate (4-6/10), and severe (7-10/10) • Quality/characteristic—aching, burning, shooting, crushing

5. What is the order of magnitude? • Lahz and Bryant: 58% mild TBI and 52% mod/severe TBI reported chronic pain. Headache was most common at 47% and 34% respectively. • Uomoto and Esselman: 95% mild TBI and 22% mod/severe TBI reported chronic pain—interesting negative correlation between frequency and severity. Reason why?

6. Beetar et al—Sleep and Pain Complaints • Compare incidence of sleep and pain complaints in symptomatic mild TBI (n=127) vs mod/severe TBI (n=75) and neurologic non-TBI (n=123) populations. • Insomnia TBI 56.4% vs 30.9% • Pain TBI 58.9% vs 22% • Pain more common in mild TBI (70%) vs mod/severe TBI (40%)

7. Relationship between pain and cognitive performance • Pain can decrease cognitive performance • Cognitive impairment can alter pain perception (is there pain while in coma?) • Cognitive and affective impairments can alter pain coping ability (perseveration, flooding, catastrophizing…..) • Pain and cognitive impairment don’t help each other.

8. Take home point #1 • The majority of individuals with TBI have chronic pain, especially in those with mild TBI. Headaches are the most common location of chronic pain, but neck and shoulder girdle pain are frequently associated. Sleep disturbances are also common. Pain and disrupted/non-restorative sleep create a vicious cycle.

9. Headaches • Migraine • Tension • Cervicogenic • Intracranial bad stuff • Combination

10. Neck Pain • Whiplash • Fracture • Herniated disk • Posture and bad mechanics

11. Evaluation • History • Physical examination • Imaging • Psych eval

12. Assessment and Treatment • Establish a likely paradigm that explains the symptoms, then initiate treatment, but follow the patient closely to make sure the paradigm is correct. Be willing to change paradigm and/or treatment if not getting results. • The best studies indicate resolution of symptoms in a matter of months (1-3 most of the time, but sometimes up to 12) for almost all adults with mild TBI. (discuss role of $ and litigation)

13. Physical Therapy • Postural correction • Muscle re-education • Mobilization • Electrical stimulation • Role of DC? • Craniosacral therapy?

14. Psychology, Neuropsychology, OT, SLP, Social Worker, Clergy • Yes. • Define what each discipline and/or person brings to the treatment • Like any other team, practice makes perfect—or at least closer to perfect • Make sure the message and goals are aligned • Avoid rewarding pain behavior • Pain is a bio-psycho-social phenomena.

15. Interventional Pain Procedures • Trigger point injections • Epidural steroid injections • Greater occipital nerve block • All have their place but selection is key

16. Medications • Pro: • Effectively reduce or eliminate pain • Easy to implement (take a pill instead of exercise) • Can reduce inflammation or hyersensitivity • Con: • Side effects (sleepy and stupid) (GI, renal, hepatic) • Addiction, dependence, tolerance • Compromised safety if cognitive impairment due to inconsistent self-administration

17. Acetominophen • Effective and generally safe • Maximum dose is 4 gm per day • May cause nausea • Available in short acting • And very cool, even for old guys like me, it comes in a longer acting “arthritis” or extended release form

18. NSAIDS • Very effective for most pain problems • Anti-inflammatory at higher doses, analgesic only at lower doses • Can be hard on stomach so use with caution in someone with history of ulcers, which raises question of safety during hospital stay (stress ulcers) • Can be hard on kidneys—use with caution in diabetes, HTN, or kidney disease—especially if using prolonged or higher doses • COX 1 and COX 2, short and long acting

19. Antidepressants • TCA’s • Duloxitine • Sleep • Anxiety • Depression • Hypersensitivity YES!

20. Anti-epileptics • Gabapentin et al • Stabilize nerve membrane? • Can be very effective for a number of pain problems • My original “sleep and stupid” medication

21. Migraine treatment • Not my thing—get a neurologist involved who treats migraine if: • Headache description is classic migraine (aura, photophobia, phonophobia, intense, etc) • Headache is not responding to other treatment—maybe it is migraine that I missed • The same thing goes for possible seizures—if the symptoms are not resolving as expected maybe there is an unrecognized seizure component that is holding the recovery back—get thee to a neurologist!

22. Opioids/narcotics • Great for pain relief but many risks for both the patient and the prescriber, especially if being used chronically—role of pain medicine specialist • Only a handful of chemical compounds • Short and long acting formulations • Dependence is to be expected if used for very long. Addiction is rare, but does occur. • Tolerance common • High risk of overuse and potential overdose if cognitively impaired—need safe system to monitor

23. Take home point #2 • There are a lot of treatment options available and it is almost always necessary to use a combination of treatments rather than a single approach. Almost everyone gets better, and most will actually resolve, but it takes time. Reassurance and direction are a key element that the team can provide in this process.

24. Questions and Thank You

25. References • Traumatic Brian Injury and Pain by Kristen Brewer Sherman, PhD, Myron Goldberg, PhD, and Kathleen R. Bell, MD. Phys Med RehabilClin N Am 17 (2006)473-490 • BeetarJT, et al. Sleep and Pain Complaints in Symptomatic Traumatic Brain Injury and Neurologic Populations. Arch Phys Med Rehabil 1996;77:1298-1302. • Lahz S, Bryant RA. Incidence of chronic pain following traumatic brain injury. Arch Phys Med Rehabil 1996; 77:889-91.