Managing Pain After Traumatic Brain InjuryApril 10, 2019
Medical advancements and aggressive interventions allow individuals with traumatic brain injury (TBI) to live longer than ever before. However, this also means that these individuals are living longer with pain. TBI pain, which can be either acute or chronic, may be attributed to nerve pain, musculoskeletal pain, or other related medical issues. Understanding an individual’s location and type of pain can aid in successful pain management.
What is Traumatic Brain Injury (TBI)?
TBI is an alteration in brain function or other brain pathology, which is caused by an external force. TBI mechanisms include those involving impact to the head (traumatic impact) and those involving inertial forces on the brain (inertial impact). They may also be caused by shockwaves from an explosion, gunshots, knife wounds, and other skull penetrating injuries. In this type of brain injury, the head is struck by or against an object. A mild type of TBI is called a concussion.
While many individuals are dealing with pain due to TBI, pain management must be determined on a case-by-case basis.
What Causes the Pain?
One of the important factors for determining both prognosis as well as treatment is whether the pain is acute or chronic.
The pain is acute if:
- It lasts less than three months; and
- It generally has an immediate or identifiable onset.
The pain is chronic if:
- It endures for more than three months;
- There is no cure; and
- It renders you disabled.
Chronic pain is all too common after TBI. Various signs and symptoms indicate whether your chronic pain is musculoskeletal or central neuropathic (nerves):
Musculoskeletal is the most common source of pain for individuals with TBI. Symptoms include aching, sharp pain that worsens with activity. This is common at the knees, hips, lower back, shoulders, elbows, and neck. A sign that an injury is musculoskeletal is if the pain worsens with joint motion or palpation.
Symptoms of central neuropathic pain include stabbing, tingling, burning, shooting pain that is episodic or continuous, but generally not related to activity. It manifests as abdominal or distal lower limb pain or follows nerve supply. A sign that an injury is central neuropathic is that the pain does not necessarily worsen with joint motion or palpation. This type of injury is also notorious for its sensitivity.
Determining a Diagnosis
How does a doctor diagnosis an individual’s TBI pain? Although physicians usually defer to clinical history in addition to conducting a physical examination, brain injury assessments can be very difficult to adequately diagnose – especially given the cognitive and communication challenges that an individual may be facing. For this reason, delayed diagnosis is actually a risk factor for chronic pain.
Fortunately, there are multiple settings where a treating physician can help with pain management. Some of these settings include:
Intensive Care Unit
When an individual is in the Intensive Care Unit with a TBI, he or she will likely be in a comatose or near-comatose state. However, there are still ways in which the body can respond to pain. The presentation of pain is reflexic, meaning that the body naturally responds even when unconscious. The doctor or nurse examining the individual must be aware of the possibility of such injury and accompanying pain. Another pain indicator is post-traumatic agitation (emotional lability, disinhibition, aggression, and inability to sit still), which is seen in approximately one-third of all brain injury survivors during the early stage of recovery.
Oftentimes, physicians are unfamiliar with some of the earlier behaviors attributable to TBI, and may resort to prescribing sedatives which can serve to hide other problems such as subclinical seizures, sleep deprivation, and changes in intracranial pressure.
Another place of treatment that may be helpful for determining pain management is in acute rehabilitation. In order for the rehabilitation itself to be effective, pain must be aggressively and accurately identified. If a person overdoes certain therapies that are involved with aggressive stretching, it can result in multiple strains and sprains. The likelihood of injury is only compounded by the fact that many individuals with TBI have cognitive impairment and difficulty with communication. Because of this, therapists must remain alert for signs of injury. The presence of pain may manifest itself in the increased combativeness of individuals though clinicians must still check for changes during physical examinations.
Spasticity is one thing physicians look for during examinations. Commonly found after moderate to severe TBI, spasticity is a condition in which certain muscles are continuously contracted. Spasticity can cause pain, weakness, muscle tightness, impaired coordination and disability. In order to treat spasticity, a clinician must understand each specific case and how it has impacted that individual. Many things can cause spasticity, such as:
- Skin rash.
- Nerve pain syndrome.
- Pressure wound.
Headaches are another major source of pain for individuals with TBI. Approximately 54 to 71 percent of people experience post-traumatic headaches shortly after the injury has occurred. About 70 percent of people with mild TBI have reported headaches for six months after injury and 40 percent experience them for even longer. Factors found to increase an individual’s risk of developing post-traumatic headaches include:
- Family history of headache disorder.
- Prior personal history of headache disorder.
- Female gender.
Those more likely to experience chronic pain in general after a TBI include:
- Personal history of post-traumatic stress disorder (PTSD).
- Personal history of psychiatric disorders.
Ultimately, research has suggested that dysfunction in the spinal cord and the brain may contribute to chronic pain after a TBI. This is especially applicable to the descending neural connections from the brain down to the spinal cord, as those tend to inhibit pain circuits.
Neurodegeneration and neuroinflammation are also potential contributors to chronic pain after TBI.
Pain Management Treatments
Many different treatments are available to help people with TBI manage their pain. One of the most important factors for risk reduction of chronic pain is early diagnosis and management of pain and psychological distress.
When an individual suffers from spasticity, lab tests, medical imaging, or electrodiagnostics are performed depending upon what a physical examination shows as the cause of the spasticity. Physical therapy and positioning techniques are basic foundational treatments that may be used. Medications, which can be prescribed topically, transdermally, intrathecally (right into the central nervous system), and orally, can also help. Other methods for targeting localized areas of spasticity treatment include:
- Motor point blocks.
- Toxin injections.
- Nerve blocks.
- Surgical procedures.
In addition, therapeutic massage has been shown to be a powerful antidote to chronic pain. Research is ongoing but already has demonstrated that massage can relax painful muscles, tendons and joints, relieve stress and anxiety, and may even counteract neurological pain messages by stimulating competing nerve fibers and impeding pain messages to and from the brain, according to Harvard Medical School. A 2014 study published in Annals of Family Medicine concluded that 60-minute therapeutic massage sessions two or three times a week for four weeks relieved chronic neck pain better than no massage or than fewer or shorter massage sessions.
Unfortunately, some individuals may experience pain long after – sometimes years after – the original trauma occurred. In fact, nearly half of trauma patients continue to experience daily pain one year after a traumatic injury, and 1 in 4 patients continue to use pain medication.
For individuals experiencing chronic nerve pain, there is no known cure. Clinicians are generally advised to follow certain steps including:
- Acknowledging an individual’s pain.
- Providing an environment that is proactive.
- Identifying and treating the pain’s underlying cause.
- Treating the pain’s exacerbating causes.
- Working on social and physical function (including exercise).
- Exploring potential psychosocial issues (e.g. smoking, poor nutrition, substance abuse).
- Range of helpful physical modalities such as motion/stretching, strengthening, etc.
- Prescription of individual medications decided on a case-by-case basis.
- Developing a strong patient-doctor relationship.
- Offering a variety of options.
- Drafting a life care plan.
Life care plans, often drafted by rehabilitation physicians, provide a process to achieve individual cost-effective care. It can be quite extensive, and can cover many categories. Such categories include:
- Medical care
- Institutional care
- Home assistance
Due to the nature of their work, members of the military are at a higher risk for TBI. Men ages 18 to 24, who comprise much of the military, are at the highest risk for TBI. Additionally, members of the military are often deployed to active war zones where they are at risk of exposure to blasts and shockwaves due to explosions.
According to research conducted in 2005 by the Defense and Veterans Brain Center (DVBIC), the blasts in combination with other mechanisms are the leading cause of TBI for active duty personnel. A 2008 review determined the prevalence of chronic headaches and pain in both civilians and combat veterans. The results showed that 51.5 percent of the civilians had chronic pain, with 57.8 percent having chronic headaches. In combat veterans those numbers were 43.1 percent and 35.9 percent respectively. Interestingly, the number of people with mild TBI experiencing chronic pain outnumbered people experiencing chronic pain with severe TBI. This may be due to the fact that those experiencing TBI have reduced cognitive awareness and additional impairments or difficulties verbally communicating.
In recent years, the Department of Veterans Affairs (VA) has implemented a nationwide system for those in need of care. New Vitae has established relationships with VA Mental Health Treatment Coordinators, and works hand-in-hand with local VA offices. Although the cost of services is generally offset by insurance, New Vitae reviews service choices and funding concerns with each individual.
TBI can have many negative effects for those who suffer from them as well as for their families. The ongoing pain related to such injuries can be both physically and mentally devastating. However, with the right understanding, diagnosis, and plan (combining pharmacologic options and psychological interventions), and specialized care, this pain can be adequately managed so that an individual, can receive relief or, at least, improve their coping mechanisms.
New Vitae = New Life
One of the most difficult aspects of seeing a loved one experience a brain injury is the behavioral health hurdle of transitioning to independent living after many skills of daily living are lost. For more than 30 years, New Vitae Wellness and Recovery Center has assisted those diagnosed with brain injuries.
Whether providing outpatient or residential treatment, New Vitae offers cutting-edge support by providing specialized treatment through Action Recovery services. These recovery services are accredited by the Commission of Rehabilitation Facilities (CARF). Some of these specialized services include:
- Assistance with daily living tasks.
- Medication administration.
- Structured day.
- Establishment and maintenance of community connections.
- Community integration.
- Prevocational work.
Life at New Vitae
Individuals receiving support through Action Recovery are assessed to determine which skill areas require the most support. Through modeling, practice, and positive reinforcement, some of the skills that can be improved include:
- Household management.
- Reading and interpreting bills.
- Meal preparation and planning.
- Clothing care.
All choices within the Action Recovery program, which include clinical services, are designed to meet the needs of each individual, their family members, and allies. Dependent upon each person’s unique situation, New Vitae offers respite care, transitional living services, and long-term care. New Vitae emphasizes trauma-informed care executed by a team of specialists. The New Vitae team includes:
- Behavior Specialists
- Certified Brain Injury Specialists
- Cognitive Therapists
- Licensed Social Workers
- Nursing Staff
- Rehabilitation Technicians
Best Traumatic Brain Injury Treatment in NJ, NY, and PA
Specializing in treatment for those with a brain injury, our facility can serve as a long-term residential treatment center for adults in Bucks County, Lehigh Valley, Quakertown, PA, NJ, and NY and beyond. For more information about New Vitae Wellness and Recovery Center and the many services it provides, contact us online or call us at 610-965-9021 today.
Among her dental, medical, and psychiatric needs, (my daughter's) care has been timely, appropriate, and excellent.- Merritt C. (family member and physician)