Analgesic Ladder in TBI Pain Management

1. Analgesic Ladder in TBI Pain Management Jim Plunkett, M.D. VA Medical Center/UC Dept of PM&R 2013 NKY TBI Conference March 22, 2013

2. Chronic Pain • IASP definition • “an unpleasant sensory or emotional response to a stimulus associated with actual or potential tissue damage” • Pain “lasting longer than the anticipated course of recovery” – often 3-6 months • Neurologic, physiologic, and emotional components ( suffering)

3. Nociceptive Pain • Noxious stimuli activating peripheral receptors producing typical acute pain along a-delta and C fibers • Pin-prick or stab wound or stubbed toe • Burn injury • Fractures

4. Neuropathic Pain • Pain associated with injury or disease of peripheral nerves • DM peripheral neuropathy • Shingles ( PHN) • Radiculopathy • Burning, shooting, lancinating pain • Allodynia, hyperpathia, central sensitization

6. Pathology: • Muscle atrophy, • weakness; • Bone loss; • Immunocomprimise • -Depression / Suicide Beginning to End: The Chronic Pain Cycle • Pathophysiology of Maintenance: • Radiculopathy • Neuroma traction • Myofascial sensitization • Brain, SC pathology (atrophy, reorganization) • Psychopathology • of maintenance: • Encoded anxiety • dysregulation • - PTSD • -Emotional • allodynia • -Mood disorder Acute injury and pain • Central • Sensitization • Neuroplastic • changes Disability Less active Kinesophobia Decreased motivation Increased isolation Role loss Peripheral Sensitization: New Na+ channels cause lower threshold Neurogenic Inflammation: - Glial activation - Pro-inflammatory cytokines - blood-nerve barrier dysruption Gallagher RM, in Ebert & Kerns, 2010)

7. Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans Chronic Pain N=277 81.5% PTSD N=232 68.2% 16.5% 2.9% 10.3% 42.1% 12.6% 6.8% TBI N=227 66.8% 5.3% Lew, Otis, Tun et al., (in Press). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD

8. WHO Analgesic Ladder 1986 • Step 1: Non-opioids (tylenol +/- NSAID) • +/- adjuvants • Step 2: “Weak opioids” • + non-opioids +/- adjuvants • Step 3: “ Strong opioids” • + non-opioids +/- adjuvants

9. Expanded Analgesic Ladder • Activity modification • Thermal modalities • Electrical topical modalities • Topical medical analgesics • Gait and mobility aides • Bracing • Stretching/ROM/massage • Strengthening • Aerobic reconditioning • Basic self-care health habits

10. Ladder ( con’t) • Non-opioids • Acetaminophen • Aspirin • NSAIDS

11. Adjuvants • Muscle relaxants • Anti-epileptic drugs ( AEDs) • Anti-depressants • Corticosteroids

12. Narcotics • Pseudo-narcotics ( tramadol) • Weak potency vs. Strong potency • Short-acting vs. Long- acting • Oral vs. topical vs. transmucosal vs. IV • Combination

13. Invasive procedures • Basic • Myofascial trigger point injections • Intra-articular injections • Botox – headache and spasticity • Acupuncture • Nerve blocks

14. Invasive procedures • Advanced: ( Fluoro-guided) • Cervical, thoracic, and lumbosacral ESI • Facet injections • Medial branch blocks • Sacro-iliac joint injections • RF nerve ablation • IDET • Stellate ganglion and LS sympathetic blocks • Celiac plexus block, Bier block

15. Quaternary Interventions • Spinal Cord ( or Dorsal column) stimulator • Intrathecal Pain pump • Rhizotomy or myelotomy • Deep Brain stimulation • Thalatomy

16. Cognitive/Behavioral therapies • Progressive relaxation • Guided imagery • Individual and Group therapy • Cognitive/behavioral therapy • Biofeedback

17. Pain Categories • “Orthopedic” • OA/DJD • Muscles, tendons, ligaments • “Neuropathic” • Myelopathy, radiculopathy • Peripheral neuropathy • Complex/Central Pain

18. Categories • Above + Chronicity help guide treatment • Other factors – Secondary Gain • Workmen’s Comp, Tort claim, SSDI • Medical co-morbidities • Traumatic Brain Injury • Age

19. Headache • Episodic Headache • Characterize type • Abortive therapy • Maximum 6 doses/week • Chronic Daily Headache • > 15 HA days per month • Analgesic rebound • Prophylaxis is key Avoid narcotics & Benzos Prophylaxis Onset of action ~ 4 wks Abortive • NSAIDs • GI side effects • Ibuprofen • Naproxen Sodium • Aspirin • Triptans • Contraindicated in • patients with CAD • Combination • Medications • Cognitive side effects • Risk of W/D • Fioricet • Fiorinal • Midrin Alternatives Promethazine Metoclopramide Prochloroperazine Tizanidine Non-medication Trigger point injection Occipital nerve block Physical therapy • Anti-depressants • May improve mood • Improves sleep • Nortriptylline • Amitryptilline • Paroxetine • Fluoxetine • AEDS • Neuropathic pain • gabapentin • Mood lability • valproic acid • topirimate • Beta-blockers • Non-selective may • have benefit on • autonomic effects of • PTSD • Propranolol

20. Drug Interactions

21. Back to Ladder details • Activity modifications • “RICE” + Lifting and positional limitations • Work hours and work pacing • Rotation of repetitive tasks • Ergonomic adjustments • Biomechanical optimization • Graduated return to work

22. Topical modalities • Ice • Heat • Topical analgesics • Capsaicin • Lidoderm • Camphor, menthol and salicylates ( Ben-gay) • Ultrasound or Iontophoresis ( steroids/NSAIDs) • TENS unit • E-stim, Biovest, Alpha stim • Cold laser

23. Gait and mobility aides • Cane • Walker incl. Rolling walker w/ fold-down seat • Wheelchair ( manual vs. electric) • Scooter

24. Orthotics • Lumbar support • Wrist splint +/- thumb spica • Elbow pads, arm sling • Soft cervical collar • Knee brace – hinged/unhinged • Ankle brace or AFO • PTB AFO • Shoe orthotic inserts, sole modifications

25. PT + HEP • Stretching/ROM/soft tissue mobilization • Strengthening – Isometric -> Isotonic • Work or activity - specific training • Plyometrics • Basic or modified aerobic reconditioning • Walking/treadmill - graduated • Bike riding – upright/recumbent • Aquatic – based • Cardiopulmonary parameters

26. Massage Therapy • Craniosacral techniques for TBI

27. Chiropractic • Manipulation • Modalities

28. Basic Selfcare – Health habits • Obesity – diet • Smoking • Alcohol • Drug abuse • Sleep hygiene • Stress management

29. Basic analgesics • Acetaminophen ( NTE 4000 mg/day) • Hepatic caveats • ASA • GI monitoring

30. NSAIDs • Salicylates • Non-acetylated ( Salsalate, Disalcid, Trilisate) • Propionic acids • Ibuprofen, Naproxen, ketoprofen, Oxaprasin • Acetic acids • Indomethacin, diclofenac, sulindac, toradol • Oxicams • Piroxicam • Cox-2 Inhibitors • Celebrex • Xyflamend – herbal - OTC

31. Muscle relaxants • Cyclobenzaprine ( TCA) • Parafon forte, methocarbamol, carisoprodol • Dantrium • Baclofen • Tizandine • Diazepam • Caveat re sedation and liver function • Soma – ( and valium) dependency

32. Neuropathic agents • Antidepressants • TCA – ami/nortriptyline, trazodone, desipramine • SSRI’s: • SNRI’s: venlafaxine, duloxetine

33. Neuropathic agents • Anti-epileptic drugs: • Carbamazepine, oxcarbazepine • Topiramate, Keppra • Gabapentin ( Neurontin) • Pregabalin ( Lyrica) • Watch for CNS SE, drug interactions esp tegretol • LFT and WBC monitoring

34. Oral steroids • Medrol dospak ( Methylprednisolone) • Prednisone taper ( 40 mg -> 0 over 12 d) • GI, DM, cataract, osteoporosis • But also watch out for Bipolar d/o

35. Narcotics • Pseudo-narcotic • Tramadol – mu agonist activity • Mild analgesia • Watch for serotonin syndrome w/ SSRI’s • Habit-forming

36. Narcotics • Mild • Propoxyphene ( Darvocet/Darvon) • No efficacy > tylenol – removed from market • Codeine • Poor GI tolerance • 2-10 % transformation to morphine

37. Narcotics • Short-acting • Oxycodone – schedule II • Hydrocodone – schedule III-> II • Meperidine ( Demerol) • Hydromorphone ( Dilaudid) • Avoid for chronic pain – rapid accommodation • Morphine IR

38. Narcotics • Long-acting • OxyContin • Morphine SR, MS Contin • Avinza, Opana • Methadone • Fentanyl patch or lollipop • Tapentadol (Nucynta)

39. Narcotic SE • Common • N/V • Constipation – proactive bowel regimen • Sedation *** Key to avoid in TBI** • Itching • Physiologic/psychological dependence • Sweating • Anorexia • Myoclonus

40. Narcotic SE • Myoclonus • Dizziness/orthostasis • Accommodation • Respiratory suppression • Cardiac dysrhythmia – methadone • Methadone also difficult to achieve equianalgesic dosing + occ idiosyncratic buildup w/ long ½ life > analgesic effect

41. Narcotic Issues • Avoid as unimodal pharmacologic approach – opioid sparing concept • Possible opioid hyperalgesia • May need to rotate type of narcotic if accommodated • Addiction vs Pseudo-addiction ( UDS) • Dependency – physiologic/psychologic • Taper ( 50 %/week) vs. Detox • Buprenex vs. methadone maintenance

42. PTSD Pain Re-experiencing Avoidance Social withdrawal Memory gaps Apathy Medication effects Pain Altered Arousal Sensitive to noise Concentration Insomnia Irritability Difficulty with decisions Mental slowness Concentration Headaches Dizzy Appetite changes Fatigue Sadness Suicidality Mild TBI Residua Substance Use (Poly) Depression

43. Conservative management of pain after TBI Rachel Heberling, MD Cincinnati VA Medical Center University of Cincinnati

44. Why Conservative Pain Management in TBI? • Increased sensitivity to medications • Increased difficulty managing medications, especially prn’s • Increased self-efficacy via self-management • Potentially decreased number of office visits • Cost-effective

45. Heat • Superficial heat: heating pad, hot shower, hot bath • Deep heat: ultrasound • Effective for pain relief, increased muscle flexibility • Not much evidence, but obviously effective briefly

46. Cold • Superficial: Ice packs • Deep: cold laser • Cold effective for pain relief and reducing inflammation, but contracts muscles • Unclear mechanism and efficacy of cold laser

47. STRETCHING! • Muscle has viscoelastic properties • Slow, deep stretch paired with deep breathing necessary • Muscle properties change for ~10 hrs after deep stretch • Evidence not compelling, but pain-relief effect of stretching is very obvious clinically

48. Stretching!

49. Other types of Exercise • Aerobic exercise – has huge role in decreasing muscle tension and consequent pain. • Strength training – some role in decreasing pain (e.g. core strengthening), but generally minimized until pain beginning to improve.

50. Meditation • Increasing base of evidence for the pain relief effects of meditation • Decreases stress • Improved emotional acceptance of pain