Conservative management of pain after TBI

Rachel Heberling, MDCincinnati VA Medical Center

University of Cincinnati

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

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

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

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

Stretching!

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.

Meditation

• Increasing base of evidence for the pain relief effects of meditation

• Decreases stress• Improved emotional acceptance of pain

Yoga

• EXCELLENT choice for exercise maintenance• Has role in decreasing active pain issues as

well.• Must start in beginner class!

Advanced Yoga Class

Tai Chi

• Becoming more popular topic of research• Have found that Tai Chi practice decreases falls

in the elderly• Somewhat similar to yoga, but more focused

on gentle fluid movement, as opposed to deep prolonged stretch

Physical Therapy

• Many treatment modalities available• Stretching• Strengthening• Ultrasound• TENS• Traction

Bracing & Assistive Devices

• Lumbar support• Knee braces• Cane• Walker

Acupuncture

Acupuncture

WHO, NIH Consensus Study

• Classified disease processes according to evidence for acupuncture efficacy

• 2003

• Proven• Needs further

research• Worth trying

Diseases, symptoms or conditions for which acupuncture has been PROVEN-through controlled trials-to be an effective treatment:

• Adverse reactions to radiotherapy and/or chemotherapyAllergic rhinitis (including hay fever)Biliary colicDepression (including depressive neurosis and depression following stroke)Dysentery, acute bacillaryDysmenorrhoea, primaryEpigastralgia, acute (in peptic ulcer, acute and chronic gastritis, and gastrospasm)Facial pain (including craniomandibular disorders)HeadacheHypertension, essentialHypotension, primary

• Induction of labourKnee painLeukopeniaLow back painMalposition of fetus, correction ofMorning sicknessNausea and vomitingNeck painPain in dentistry (including dental pain and temporomandibular dysfunction)Periarthritis of shoulderPostoperative painRenal colicRheumatoid arthritisSciaticaSprainStrokeTennis elbow

WHO Acupuncture and The NIH Consensus Study

Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which FURTHER

PROOF IS NEEDED:

• Abdominal pain (in acute gastroenteritis or due to gastrointestinal spasm)Acne vulgarisAlcohol dependence and detoxificationBell’s palsyBronchial asthmaCancer painCardiac neurosisCholecystitis, chronic, with acute exacerbationCholelithiasisCompetition stress syndromeCraniocerebral injury, closedDiabetes mellitus, non-insulin-dependentEaracheEpidemic haemorrhagic feverEpistaxis, simple (without generalized or local disease)

• Eye pain due to subconjunctival injectionFemale infertilityFacial spasmFemale urethral syndromeFibromyalgia and fasciitisGastrokinetic disturbanceGouty arthritisHepatitis B virus carrier statusHerpes zoster (human (alpha) herpesvirus 3)HyperlipaemiaHypo-ovarianismInsomniaLabour painLactation, deficiencyMale sexual dysfunction, non-organic Ménière diseaseNeuralgia, post-herpetic

WHO Acupuncture and The NIH Consensus Study

Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which FURTHER

PROOF IS NEEDED:

• NeurodermatitisObesityOpium, cocaine and heroin dependenceOsteoarthritisPain due to endoscopic examinationPain in thromboangiitis obliteransPolycystic ovary syndrome (Stein-Leventhal syndrome)Postextubation in childrenPostoperative convalescencePremenstrual syndromeProstatitis, chronicPruritusRadicular and pseudoradicular pain syndromeRaynaud syndrome, primary

• Recurrent lower urinary-tract infectionReflex sympathetic dystrophyRetention of urine, traumaticSchizophreniaSialism, drug-inducedSjögren syndromeSore throat (including tonsillitis)Spine pain, acuteStiff neckTemporomandibular joint dysfunctionTietze syndromeTobacco dependenceTourette syndromeUlcerative colitis, chronicUrolithiasisVascular dementiaWhooping cough (pertussis)

WHO Acupuncture and The NIH Consensus Study

Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which

acupuncture is WORTH TRYING because treatment by conventional and other therapies is difficult:

• Chloasma

• Choroidopathy, central serous

• Colour blindness

• Deafness

• Hypophrenia

• Neuropathic bladder in spinal cord injury

• Pulmonary heart disease, chronic

• Small airway obstruction

• Irritable colon syndrome

GERAC – Design– Journal of Alternative and Complementary Medicine. Volume 12, Number 8,

2006. pp 733-42

– German Acupuncture Trials for Low Back Pain– 1162 patients in Germany at 340 centers– Chronic non-specific low back pain >6 months– Compared verde vs sham vs conventional

guideline-based treatment– Semi-standardized verde acupuncture treatment

protocol

GERAC – Design

• 10 sessions over 10 weeks regardless of group• 5 additional sessions for partial responders

(>10%, <50% improvement)• Limited communication with acupuncturist to

avoid unblinding• Allowed NSAID for rescue, max twice weekly.

GERAC - ResultsTable 4. Primary Outcome: Pairwise Comparisonof Treatment Response 6 Months After Randomization

Treatment Response Intergroup Difference P ValueGroup 1 vs group 347.6 (42.4 to 52.6) vs 20.2 (13.4 to 26.7) 0.00127.4 (23.0 to 32.1)

Group 2 vs group 344.2 (39.2 to 49.3) vs 16.8 (10.1 to 23.4) 0.00127.4 (23.0 to 32.1)

Group 1 vs group 2 3.4 (−3.7 to 10.3) 0.3947.6 (42.4 to 52.6) vs 44.2 (39.2 to 49.3)

GERAC - Results• Treatment Response After 6 Months• Conventional Sham Acupuncture Verum Acupuncture• CPGS• Success 132 (34.1) 197 (50.9) 229 (59.2)• HFAQ• Success 195 (50.4) 251 (64.9) 281 (72.6)• Combined CPGS and HFAQ• Success 223 (57.6) 277 (71.6) 304 (78.5)

• Combined GCPS, HFAQ• Nonresponders 164 (42.4) 125 (32.3) 112 (28.9)• Responders 223 (57.6) 262 (67.7) 275 (71.1)

• Overall treatment response including proscribed rescue medication• Nonresponders 281 (72.6) 216 (55.8) 203 (52.4)• Responders 106 (27.4) 171 (44.2) 184 (47.6)