Transcript Managing Chronic Pain in Individuals with Brain Injury

Managing Chronic Pain in
Individuals with Brain Injury
Kenneth R Britton, DO MMM
Britton Pain Clinic
St. Paul, MN
Introduction
• Interaction with the audience, including:
– Who I am
– Who the audience is
– What does the audience want to discuss about
pain and TBI
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
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
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?
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%)
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.
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.
Headaches
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Migraine
Tension
Cervicogenic
Intracranial bad stuff
Combination
Neck Pain
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Whiplash
Fracture
Herniated disk
Posture and bad mechanics
Evaluation
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History
Physical examination
Imaging
Psych eval
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)
Physical Therapy
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Postural correction
Muscle re-education
Mobilization
Electrical stimulation
• Role of DC?
• Craniosacral therapy?
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.
Interventional Pain Procedures
• Trigger point injections
• Epidural steroid injections
• Greater occipital nerve block
• All have their place but selection is key
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
Acetominophen
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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
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
Antidepressants
• TCA’s
• Duloxitine
• Sleep
• Anxiety
• Depression
• Hypersensitivity
YES!
Anti-epileptics
• Gabapentin et al
• Stabilize nerve membrane?
• Can be very effective for a number of pain
problems
• My original “sleep and stupid” medication
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!
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
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.
Questions and Thank You
References
• Traumatic Brian Injury and Pain by Kristen Brewer
Sherman, PhD, Myron Goldberg, PhD, and
Kathleen R. Bell, MD. Phys Med Rehabil Clin N Am
17 (2006)473-490
• Beetar JT, 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.