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Riganello F, Tonin P, Soddu A. I Feel! Therefore, I Am from Pain to Consciousness in DOC Patients. Int J Mol Sci 2023; 24:11825. [PMID: 37511583 PMCID: PMC10380260 DOI: 10.3390/ijms241411825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Pain assessment and management in patients with disorders of consciousness (DOC) is a challenging and important aspect of care, with implications for detecting consciousness and promoting recovery. This narrative review explores the role of pain in consciousness, the challenges of pain assessment, pharmacological treatment in DOC, and the implications of pain assessment when detecting changes in consciousness. The review discusses the Nociception Coma Scale and its revised version, which are behavioral scales used to assess pain in DOC patients, and the challenges and controversies surrounding the appropriate pharmacological treatment of pain in these patients. Moreover, we highlight recent evidence suggesting that an accurate pain assessment may predict changes in the level of consciousness in unresponsive wakefulness syndrome/vegetative state patients, underscoring the importance of ongoing pain management in these patients.
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Affiliation(s)
- Francesco Riganello
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Paolo Tonin
- Research in Advanced Neurorehabilitation, S. Anna Institute, 88900 Crotone, Italy
| | - Andrea Soddu
- Physics, and Astronomy Department, Western Institute for Neuroscience, University of Western Ontario, London, ON N6A 3K7, Canada
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2
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Sahbaie P, Irvine KA, Shi XY, Clark JD. Monoamine control of descending pain modulation after mild traumatic brain injury. Sci Rep 2022; 12:16359. [PMID: 36175479 PMCID: PMC9522857 DOI: 10.1038/s41598-022-20292-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/12/2022] [Indexed: 12/25/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant public health concern, with the majority of injuries being mild. Many TBI victims experience chronic pain. Unfortunately, the mechanisms underlying pain after TBI are poorly understood. Here we examined the contribution of spinal monoamine signaling to dysfunctional descending pain modulation after TBI. For these studies we used a well-characterized concussive model of mild TBI. Measurements included mechanical allodynia, the efficacy of diffuse noxious inhibitory control (DNIC) endogenous pain control pathways and lumber norepinephrine and serotonin levels. We observed that DNIC is strongly reduced in both male and female mice after mild TBI for at least 12 weeks. In naïve mice, DNIC was mediated through α2 adrenoceptors, but sensitivity to α2 adrenoceptor agonists was reduced after TBI, and reboxetine failed to restore DNIC in these mice. The intrathecal injection of ondansetron showed that loss of DNIC was not due to excess serotonergic signaling through 5-HT3 receptors. On the other hand, the serotonin-norepinephrine reuptake inhibitor, duloxetine and the serotonin selective reuptake inhibitor escitalopram both effectively restored DNIC after TBI in both male and female mice. Therefore, enhancing serotonergic signaling as opposed to noradrenergic signaling alone may be an effective pain treatment strategy after TBI.
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Affiliation(s)
- Peyman Sahbaie
- grid.168010.e0000000419368956Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA 94305 USA ,grid.280747.e0000 0004 0419 2556Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave (E4-220), Palo Alto, CA 94304 USA
| | - Karen-Amanda Irvine
- grid.168010.e0000000419368956Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA 94305 USA ,grid.280747.e0000 0004 0419 2556Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave (E4-220), Palo Alto, CA 94304 USA
| | - Xiao-you Shi
- grid.168010.e0000000419368956Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA 94305 USA ,grid.280747.e0000 0004 0419 2556Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave (E4-220), Palo Alto, CA 94304 USA
| | - J. David Clark
- grid.168010.e0000000419368956Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA 94305 USA ,grid.280747.e0000 0004 0419 2556Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave (E4-220), Palo Alto, CA 94304 USA
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3
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Jang SH, Kim SH, Kwon HG. Diagnostic sensitivity of traumatic axonal injury of the spinothalamic tract in patients with mild traumatic brain injury. Medicine (Baltimore) 2022; 101:e28536. [PMID: 35029922 PMCID: PMC8735717 DOI: 10.1097/md.0000000000028536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/16/2021] [Indexed: 12/03/2022] Open
Abstract
Diffusion tensor tractography (DTT) can detect traumatic axonal injury (TAI) in patients whose conventional brain magnetic resonance imaging results are negative. This study investigated the diagnostic sensitivity of TAI of the spinothalamic tract (STT) in patients with a mild traumatic brain injury (TBI) suffering from central pain symptoms, using DTT.Thirty-five patients with central pain following mild TBI and 30 healthy control subjects were recruited for this study. After DTT-based reconstruction of the STT, we analyzed the STT in terms of configuration (narrowing and/or tearing) and the DTT parameters (fractional anisotropy and tract volume).Thirty-three (94.3%) patients had at least 1 DTT parameter value at 1 standard deviation below the control group value, and 20 (57.1%) patients had values at 2 standard deviations, below the control group value. All 35 patients showed STT abnormalities (tearing, narrowing, or both) on DTT.A high diagnostic sensitivity of TAI of the STT in patients with mild TBI was achieved. However, the small number of subjects who visited the university hospital and the limitations of DTT should be considered when generalizing the results of this study.
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Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Republic of Korea
| | - Seong Ho Kim
- Department of Neurosurgery, College of Medicine, Yeungnam University, Republic of Korea
| | - Hyeok Gyu Kwon
- Department of Physical Therapy, College of Health Science, Eulji University, Republic of Korea
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4
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Risk Factors Associated With the Prescription of Opioids Among Service Members Following a First Mild Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:345-353. [PMID: 34489385 DOI: 10.1097/htr.0000000000000711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate factors impacting opioid receipt among active-duty service members (SMs) following a first mild traumatic brain injury (mTBI). SETTING Active-duty SMs receiving care within the Military Health System. PARTICIPANTS In total, 14 757 SMs who have sustained an initial mTBI, as documented within electronic health records (EHRs), between 2016 and 2017. DESIGN A retrospective analysis of EHR metadata. MAIN MEASURES Multivariable logistic regression assessed factors impacting opioid receipt and initiation. Factors include demographics, military characteristics, and preexisting clinical conditions, including prior opioid prescription. RESULTS Of the sample population, 33.4% (n = 4927) were prescribed opioids after their initial mTBI, of which, 60.6% (n = 2985) received opioids for the first time following injury. Significant risk factors associated with the increased probability of opioid receipt included age, gender, and preexisting behavioral health and musculoskeletal conditions. Military characteristics also exhibited changes in the probability of opioid receipt, both among initiation and new prescription. No changes were observed among race, nor among those with preexisting headaches or migraines. CONCLUSION Despite concerns about the negative impact on recovery, the prescribing of opioids is common in this population of active-duty SMs first diagnosed with an mTBI. As several demographic and preexisting health conditions are factors in the receipt of opioids post-mTBI, the entire medical history of these patients should be considered prior to prescription. Understanding these factors may further inform policy for opioid use in the Military Health System.
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5
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Portanova J, Buchanan D, Moore M, Thompson H. Factors Associated with the Development of Persistent Pain after mTBI. Pain Manag Nurs 2021; 22:592-598. [PMID: 34011466 DOI: 10.1016/j.pmn.2021.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/29/2021] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Persistent pain after mild traumatic brain injury (mTBI) is widely experienced, yet little is known about who is at risk for experiencing persistent pain after their injury. AIMS The purpose of this study was to 1) determine if there are factors associated with later experiencing persistent pain after mTBI and 2) examine if there are symptom patterns associated with the experience of persistent pain. DESIGN Secondary analysis was conducted using de-identified data from an NIH-funded longitudinal study.SettingsParticipants were enrolled in the emergency department. PARTICIPANTS Participants were aged 21 to 92 and all had experienced mTBI. METHODS We examined baseline characteristics, symptoms, and injury related variables associated with the endorsement of persistent pain among those with mTBI (N = 183) from baseline to 6 months post-injury. In order to identify a persistent pain phenotype, exploratory factor analysis was used to determine which symptoms co-occur with persistent pain. RESULTS Persistent pain was found in 78% of those with mTBI. Those with lower overall health status at day 7 and at 1-month following injury had greater odds of developing persistent pain. Those with higher levels of general health status and physical function health status at day 7 and 1 month, and those with higher levels of overall health related status at 1 month had significantly lesser odds of persistent pain at 6 months. Factor analysis revealed that persistent pain and co-occurring symptoms (anxiety, depression, dizziness, nausea and vomiting, sleep disturbance, poor memory, poor concentration, longer to think and light sensitivity) loaded on one factor, indicating that these symptoms are associated. CONCLUSIONS Those at increased risk for persistent pain should be screened beginning early in the recovery trajectory to reduce their risk of developing persistent pain. Identification of a phenotype offers potential for recognition of symptoms that cluster with persistent pain, improving the ability to treat patients more holistically, and develop interventions to support recovery from injury.
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Affiliation(s)
- Jaclyn Portanova
- University of Washington, Seattle, Washington; Department of Veteran Affairs; Linfield University; Yale University.
| | | | - Megan Moore
- University of Washington, Seattle, Washington
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Riganello F, Soddu A, Tonin P. Addressing Pain for a Proper Rehabilitation Process in Patients With Severe Disorders of Consciousness. Front Pharmacol 2021; 12:628980. [PMID: 33679413 PMCID: PMC7926206 DOI: 10.3389/fphar.2021.628980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/08/2021] [Indexed: 01/18/2023] Open
Abstract
Consciousness constitutes a fundamental prerequisite in the individual appraisal and experience of pain. In the same way, a person needs to be able to report on pain perception. Patients who suffered a severe brain injury with disorders of consciousness (DOC) represent a spectrum of pathologies affecting patients' capacity to interact with the external world. In these patients, the most relevant aspects in response to pain are physiologic and behavioral. The treatments and management of pain are challenging issues in these patients, arising serious ethical concerns and bringing emotional load among medical staff, caregivers, and relatives. In this review, we report the importance of having a correct pain management in DOC patients, to individuate the best pharmacological treatment that can make the difference in detecting a behavioral response, indicative of a change in the level of consciousness, and in planning a more effective rehabilitative approach.
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Affiliation(s)
- F. Riganello
- Research in Advanced NeuroRehabilitation, Istituto Sant’Anna, Crotone, Italy
| | - A. Soddu
- Department of Physics and Astronomy, Brain and Mind Institute, Western University, London, ON, Canada
| | - P. Tonin
- Research in Advanced NeuroRehabilitation, Istituto Sant’Anna, Crotone, Italy
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The Protective Role of Nutraceuticals in Critically Ill Patients with Traumatic Brain Injury. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1328:243-253. [DOI: 10.1007/978-3-030-73234-9_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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8
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Kang DH, Kim GW. Changes in Diffuse Tensor Imaging and Therapeutic Effect of Repetitive Transcranial Magnetic Stimulation in Traumatic Brain Injury with Central Pain. Brain Sci 2020; 10:brainsci10120929. [PMID: 33276440 PMCID: PMC7759834 DOI: 10.3390/brainsci10120929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 12/21/2022] Open
Abstract
Post-trauma chronic pain characterized by central pain is a symptom following traumatic brain injury (TBI). Studies on the effect of repetitive transcranial magnetic stimulation (rTMS) on central pain and the association between central pain and spinothalamic tract (STT) have been reported, but few studies have examined the effect of rTMS in patients with mild TBI with central pain through changes in diffusion tensor imaging (DTI)-based metrics of STT before and after rTMS. This case series aimed to investigate the therapeutic effect of rTMS in TBI with central pain and the changes in diffusion tensor imaging (DTI)-based metrics of the spinothalamic tract (STT) before and after rTMS. This study included four patients who complained of severe pain in the left or right side of the body below the neck area after a car accident. We performed numeric rating scale (NRS), bedside sensory examination, electrodiagnostic study, and DTI-based metrics of the STT before and after rTMS. According to the guidelines of the diagnosis and grading for neuropathic pain, all patients had neuropathic pain corresponding to “probable grade.” In all patients, rTMS was applied to the contralateral M1 cortex on the more painful side. There were no medication changes and other interventions during the rTMS. After rTMS, NRS decreased, bed sensory testing improved, and DTI-based STT metrics increased in all patients compared to before rTMS.
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Affiliation(s)
- Dong-Ha Kang
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, Korea;
- Research Institute of Clinical Medicine of Jeonbuk National University—Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Korea
| | - Gi-Wook Kim
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, Korea;
- Research Institute of Clinical Medicine of Jeonbuk National University—Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Korea
- Correspondence: ; Tel.: +82-10-5279-1421
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9
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Traumatic brain injury and the misuse of alcohol, opioids, and cannabis. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2020; 157:195-243. [PMID: 33648670 DOI: 10.1016/bs.irn.2020.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Traumatic brain injury (TBI), most often classified as concussion, is caused by biomechanical forces to the brain resulting in short- or long-term impairment in brain function. TBI resulting from military combat, sports, violence, falls, and vehicular accidents is a major cause of long-term physical, cognitive, and psychiatric dysfunction. Psychiatric disorders associated with TBI include depression, anxiety, and substance use disorder, all having significant implications for post-TBI recovery and rehabilitation. This chapter reviews the current preclinical and clinical literature describing the bidirectional relationship between TBI and misuse of three commonly abused drugs: alcohol, opioids, and cannabis. We highlight the influence of each of these drugs on the incidence of TBI, as well as trends in their use after TBI. Furthermore, we discuss factors that may underlie post-injury substance use. Understanding the complex relationship between TBI and substance misuse will enhance the clinical treatment of individuals suffering from these two highly comorbid conditions.
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10
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Hammond FM, Ketchum J, Dams-O'Connor K, Corrigan JD, Miller C, Haarbauer-Krupa J, Faul M, Trexler LE, Harrison-Felix C. Mortality Secondary to Unintentional Poisoning after Inpatient Rehabilitation among Individuals with Moderate to Severe Traumatic Brain Injury. J Neurotrauma 2020; 37:2507-2516. [PMID: 32438850 DOI: 10.1089/neu.2020.7038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Studies have shown reduced life expectancy following moderate-severe traumatic brain injury (TBI) with death from unintentional poisoning (UP) being 11 times higher following TBI than in the general population. The characteristics of those who die of unintentional poisoning are compared with the characteristics of those who die of other causes (OC) in a retrospective cohort who received inpatient rehabilitation following TBI and enrolled in the TBI Model Systems National Database between 1989 and 2017 (n = 15,835 cases with 2,238 deaths recorded). Seventy-eight cases (3.5%) of deaths were the result of UP, 76% were the result of OC, and 20.5% were from an unknown cause. Among the UP deaths, 90% involved drugs (of these, 67% involved narcotic drugs and 14% involved psychostimulants), and 8% involved alcohol. Age-adjusted risk for UP death was associated with: white/non-Hispanic race/ethnicity, living alone, non-institutionalization, pre- and post-injury illicit drug use and alcohol/drug problem use, any alcohol use at last follow-up, better Functional Independence MeasureTM (FIM) scores, history of arrest, moderate disability (vs. severe disability or good recovery), less supervision needed, and greater anxiety. Adults who receive inpatient rehabilitation for TBI who die from UP are distinguishable from those who die of OC. Factors such as pre-injury substance use in the context of functional independence may be regarded as targets for prevention and/or intervention to reduce substance use and substance-related mortality among survivors of moderate-severe TBI. The current findings may have implications for medical care, surveillance, prevention, and health promotion.
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Affiliation(s)
- Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Jessica Ketchum
- Research Department, Craig Hospital, Englewood, Colorado, USA.,Traumatic Brain Injury Model Systems National Data and Statistical Center, Englewood, Colorado, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John D Corrigan
- Department of Physical Medicine & Rehabilitation, Ohio State University, Columbus, Ohio, USA
| | - Cate Miller
- National Institute on Disability, Independent Living, and Rehabilitation Research, Administration for Community Living, Department of Health and Human Services, Washington, DC, USA
| | - Juliet Haarbauer-Krupa
- Traumatic Brain Injury Team, Division of Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mark Faul
- Traumatic Brain Injury Team, Division of Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lance E Trexler
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Cynthia Harrison-Felix
- Research Department, Craig Hospital, Englewood, Colorado, USA.,Traumatic Brain Injury Model Systems National Data and Statistical Center, Englewood, Colorado, USA
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11
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Leung A. Addressing chronic persistent headaches after MTBI as a neuropathic pain state. J Headache Pain 2020; 21:77. [PMID: 32560626 PMCID: PMC7304149 DOI: 10.1186/s10194-020-01133-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/25/2020] [Indexed: 12/15/2022] Open
Abstract
An increasing number of patients with chronic persistent post-traumatic headache (PPTH) after mild traumatic brain injury (MTBI) are being referred to headache or pain specialists as conventional treatment options for primary headache disorders have not been able to adequately alleviate their debilitating headache symptoms. Evolving clinical and mechanistic evidences support the notation that chronic persistent MTBI related headaches (MTBI-HA) carry the hallmark characteristics of neuropathic pain. Thus, in addition to conventional treatment options applicable to non-traumatic primary headache disorders, other available treatment modalities for neuropathic pain should be considered. In this comprehensive review article, the author reveals the prevalence of MTBI-HA and its clinical manifestation, discusses existing clinical and mechanistic evidence supporting the classification of chronic persistent MTBI-HA as a neuropathic pain state, and explores current available treatment options and future directions of therapeutic research related to MTBI-HA.
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Affiliation(s)
- Albert Leung
- Department of Anesthesiology, Center for Pain Medicine, UCSD School of Medicine, La Jolla, USA.
- Center for Pain and Headache Research, VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA, 92126, USA.
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12
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Adams RS, Corrigan JD, Dams-O'Connor K. Opioid Use among Individuals with Traumatic Brain Injury: A Perfect Storm? J Neurotrauma 2019; 37:211-216. [PMID: 31333067 DOI: 10.1089/neu.2019.6451] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.,VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
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13
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Avallone KM, Smith ER, Ma S, Gargan S, Porter KE, Authier CC, Martis B, Liberzon I, Rauch SAM. PTSD as a Mediator in the Relationship Between Post-Concussive Symptoms and Pain Among OEF/OIF/OND Veterans. Mil Med 2019; 184:e118-e123. [PMID: 30215758 DOI: 10.1093/milmed/usy225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/08/2018] [Indexed: 11/12/2022] Open
Abstract
Introduction Traumatic brain injury (TBI), pain, and post-traumatic stress disorder (PTSD) commonly co-occur in Veteran populations, particularly among Veterans returning from the recent conflicts in Iraq and Afghanistan. Extant research indicates that both TBI and PTSD can negatively impact pain broadly; however, less is known about how these variables impact one another. The current study examines the impact of self-reported post-concussive symptoms on both pain severity and pain interference among Veterans with PTSD who screened positive for a possible TBI, and subsequently, evaluates the potential mediating role of PTSD in these relationships. Materials and Methods Participants were 126 combat Veterans that served in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn who were being evaluated for participation in a multisite treatment outcomes study. As part of an initial evaluation for inclusion in the study, participants completed several self-report measures and interviews, including the Brief Traumatic Brain Injury Screen, Neurobehavioral Symptom Inventory, Brief Pain Inventory, and the Clinician Administered PTSD Scale, which were utilized in these analyses. Results For pain severity, greater post-concussive symptoms significantly predicted increased pain severity with a significant indirect effect of post-concussive symptoms on pain severity through PTSD (indirect effect = 0.03; 95% confidence interval = 0.0094-0.0526). Similar results were found for pain interference (indirect effect = 0.03; 95% confidence interval = 0.0075-0.0471). Conclusions These findings replicate and extend previous findings regarding the relationship between TBI, pain, and PTSD. Self-reported post-concussive symptoms negatively impact both pain severity and pain interference among Veterans with probable TBI, and PTSD serves as a mediator in these relationships. Clinically, these results highlight the importance of fully assessing for PTSD symptoms in Veterans with a history of TBI presenting with pain. Further, it is possible that providing effective PTSD treatment to reduce PTSD severity may provide some benefit in reducing post-concussive and pain symptoms.
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Affiliation(s)
- Kimberly M Avallone
- Mental Health Service, VA Ann Arbor Healthcare System, 2215 Fuller Rd Ann Arbor, MI.,Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Erin R Smith
- Mental Health Service, VA Ann Arbor Healthcare System, 2215 Fuller Rd Ann Arbor, MI.,Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Sean Ma
- Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Sean Gargan
- Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Katherine E Porter
- Mental Health Service, VA Ann Arbor Healthcare System, 2215 Fuller Rd Ann Arbor, MI.,Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Caitlin C Authier
- Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Brian Martis
- Mental Health Service, VA Ann Arbor Healthcare System, 2215 Fuller Rd Ann Arbor, MI.,Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Israel Liberzon
- Mental Health Service, VA Ann Arbor Healthcare System, 2215 Fuller Rd Ann Arbor, MI.,Department of Psychiatry, University of Michigan, 500S State St Ann Arbor, MI
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 1648 Pierce Dr NE Atlanta, GA.,Mental Health Service Line, Atlanta VA Medical Center, 1670 Clairmont Rd. Decatur, GA
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14
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Niu X, Bai L, Sun Y, Wang S, Cao J, Sun C, Wang Z, Xu H, Gan S, Fan G, Huang W, Gu C, Yin B, Bai G, Xu X, Zhang M. Disruption of periaqueductal grey-default mode network functional connectivity predicts persistent post-traumatic headache in mild traumatic brain injury. J Neurol Neurosurg Psychiatry 2019; 90:326-332. [PMID: 30554137 DOI: 10.1136/jnnp-2018-318886] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/01/2018] [Accepted: 11/13/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Post-traumatic headache (PTH) is one of the most frequent and persistent physical symptoms following mild traumatic brain injury (mTBI) and develop in more than 50% of this population. This study aimed to investigate the periaqueductal grey (PAG)-seeded functional connectivity (FC) in patients with mTBI with acute post-traumatic headache (APTH) and further examine whether the FC can be used as a neural biomarker to identify patients developing chronic pain 3 months postinjury. METHODS 70 patients with mTBI underwent neuropsychological measurements and MRI scans within 7 days postinjury and 56 (80%) of patients were followed up at 3 months. 46 healthy controls completed the same protocol on recruitment to the study. PAG-seeded resting-state FC analysis was measured in 54 patients with mTBI with APTH, in comparison with 46 healthy volunteers. RESULTS The mTBI+APTH group presented significantly reduced PAG-seeded FC within the default mode network (DMN), compared with healthy volunteers group. The connectivity strength can also predict patients' complaints on the impact of headache on their lives. Crucially, the initial FC strength between the PAG-right precuneus as well as the PAG-right inferior parietal lobule became the important predictor to identify patients with mTBI developing persistent PTH 3 months postinjury. CONCLUSIONS Patients with mTBI+APTH exhibited significant PAG-related FC differences mainly within the DMN. These regions extended beyond traditional pain processing areas and may reflect the diminished top-down attention regulation of pain perception through antinociceptive descending modulation network. The disrupted PAG-DMN FC may be used as an early imaging biomarker to identify patients at risk of developing persistent PTH.
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Affiliation(s)
- Xuan Niu
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lijun Bai
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Yingxiang Sun
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shan Wang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Jieli Cao
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Chuanzhu Sun
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Zhuonan Wang
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hui Xu
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Shuoqiu Gan
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Geng Fan
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Wenmin Huang
- The Key Laboratory of Biomedical Information Engineering, Ministry of Education, Department of Biomedical Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Chenghui Gu
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Xi'an, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Xi'an, China
| | - Guanghui Bai
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Xi'an, China
| | - Xiaoling Xu
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ming Zhang
- Department of Medical Imaging, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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15
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Zhou Y, Greenwald BD. Update on Insomnia after Mild Traumatic Brain Injury. Brain Sci 2018; 8:brainsci8120223. [PMID: 30551607 PMCID: PMC6315624 DOI: 10.3390/brainsci8120223] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/08/2018] [Accepted: 12/11/2018] [Indexed: 12/16/2022] Open
Abstract
Sleep disturbance after traumatic brain injury (TBI) has received growing interest in recent years, garnering many publications. Insomnia is highly prevalent within the mild traumatic brain injury (mTBI) population and is a subtle, frequently persistent complaint that often goes undiagnosed. For individuals with mTBI, problems with sleep can compromise the recovery process and impede social reintegration. This article updates the evidence on etiology, epidemiology, prognosis, consequences, differential diagnosis, and treatment of insomnia in the context of mild TBI. This article aims to increase awareness about insomnia following mTBI in the hopes that it may improve diagnosis, evaluation, and treatment of sleeping disturbance in this population while revealing areas for future research.
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Affiliation(s)
- Yi Zhou
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ 08854, USA.
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Morris TP, Costa-Miserachs D, Rodriguez-Rajo P, Finestres J, Bernabeu M, Gomes-Osman J, Pascual-Leone A, Tormos-Muñoz JM. Feasibility of Aerobic Exercise in the Subacute Phase of Recovery From Traumatic Brain Injury: A Case Series. J Neurol Phys Ther 2018; 42:268-275. [PMID: 30138231 PMCID: PMC6131086 DOI: 10.1097/npt.0000000000000239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Aerobic exercise is as important for individuals with traumatic brain injury (TBI) as for the general population; however, the approach to aerobic training may require some adaptation. The objective of the trial program was to examine the feasibility of introducing aerobic physical exercise programs into the subacute phase of multidisciplinary rehabilitation from moderate to severe TBI, which includes computerized cognitive training. CASE DESCRIPTION Five individuals undergoing inpatient rehabilitation with moderate or severe TBIs who also have concomitant physical injuries. All of these individuals were in the subacute phase of recovery from TBIs. INTERVENTION An 8-week progressive aerobic physical exercise program. Participants were monitored to ensure that they could both adhere to and tolerate the exercise program. In addition to the physical exercise, individuals were undergoing their standard rehabilitation procedures that included cognitive training. Neuropsychological testing was performed to gain an understanding of each individual's cognitive function. OUTCOMES Participants adhered to both aerobic exercise and cognitive training. Poor correlations were noted between heart rate reserve and ratings of perceived effort. Two minor adverse events were reported. DISCUSSION Despite concomitant physical injuries and cognitive impairments, progressive aerobic exercise programs seem feasible and well tolerated in subacute rehabilitation from moderate to severe TBI. Findings highlight the difficulty in measuring exercise intensity in this population.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A235).
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Affiliation(s)
- Timothy P Morris
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Badalona, Barcelona, Spain (T.P.M., P.R.R., J.F., M.B., A.P.L., J.M.T.M.); Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain (P.R.R., J.F., M.B., J.M.T.M.); Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (T.P.M., J.G.O., A.P.L.); Departament de Psicobiologia i Ciències de la Salut, Institut de Neurociències, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain (T.P.M., D.C.M.); and Department of Physical Therapy, University of Miami, Miller School of Medicine, Miami, Florida (J.G.O.)
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17
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Mehalick ML, Glueck AC. Examining the relationship and clinical management between traumatic brain injury and pain in military and civilian populations. Brain Inj 2018; 32:1307-1314. [PMID: 29993307 DOI: 10.1080/02699052.2018.1495339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In this review, we discuss the comorbidity of traumatic brain injury (TBI) and pain among civilians and military members, the common causes of pain resulting from TBI, and offer insight about the therapeutic management of TBI symptoms and pain. Traumatic brain injury (TBI) is a debilitating health problem and one of the most common post-TBI symptoms is pain, which can contribute to psychological issues such as Post-traumatic stress disorder (PTSD) and depression. Headache pain appears to be the most common type of pain that results from TBI, yet pain can also be more widespread. Managing TBI symptoms and pain simultaneously is difficult because extensive randomized control and clinical studies assessing the effectiveness of therapeutic approaches are lacking. Pharmacological agents such as antidepressants and Triptans and nonpharmacological therapies such as cognitive rehabilitation and physical therapies are commonly used yet it is unknown how effective these therapies are in the long-term. A combination of pharmacological and non-pharmacological therapies is often more effective for managing TBI symptoms and pain than either treatment alone. However, future research is needed to determine the most therapeutic approaches for managing the comorbidity of pain and TBI symptoms in the long term. This review offers suggestions for such future studies.
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Affiliation(s)
- Melissa L Mehalick
- a Department of Neurotrauma, Operational and Undersea Medicine Directorate , Naval Medical Research Center , Silver Spring , MD, USA
| | - Amanda C Glueck
- b Sports Medicine Research Institute , University of Kentucky , Lexington , KY, USA
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18
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Hudson TJ, Painter JT, Gressler LE, Lu L, Williams JS, Booth BM, Martin BC, Sullivan MD, Edlund MJ. Factors Associated with Opioid Initiation in OEF/OIF/OND Veterans with Traumatic Brain Injury. PAIN MEDICINE (MALDEN, MASS.) 2018; 19:774-787. [PMID: 29036680 PMCID: PMC6659014 DOI: 10.1093/pm/pnx208] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective These analyses examined opioid initiation and chronic use among Iraq (OIF) and Afghanistan (OEF/OND) veterans with a new diagnosis of traumatic brain injury (TBI) in the Veterans Health Administration (VHA). Methods Data were obtained from national VHA data repositories. Analyses included OEF/OIF/OND veterans with a new TBI diagnosis in 2010-2012 who used the VHA at least twice, had not received a VHA opioid prescription in the 365 days before diagnosis, and had at least 365 days of data available after TBI diagnosis. Results Analyses included 35,621 veterans. Twenty-one percent initiated opioids; among new initiators, 23% used chronically. The mean dose was 24.0 mg morphine equivalent dose (MED) daily (SD = 24.26); mean days supplied was 60.52 (SD = 74.69). Initiation was significantly associated with age 36-45 years (odds ratio [OR] = 1.09, 95% CI = 1.01-1.17, P = 0.04), female gender (OR = 1.22, P < 0.001), having back pain (OR = 1.38, P < 0.0001), arthritis/joint pain (OR = 1.24, P < 0.0001), or neuropathic pain (OR = 1.415, P < 0.02). In veterans age 36-45 years, those living in small rural areas had higher odds of chronic opioid use (OR = 1.31, P < 0.0001, and OR = 1.33, P = 0.006, respectively) and back pain (OR = 1.36, P = 0.003). Headache/migraine pain was associated with decreased odds of chronic opioid use (OR = 0.639, P = 0.003). Conclusions Prevalence of opioid use is relatively low among OEF/OIF/OND veterans with newly diagnosed TBI who are using VHA. Among those who initiated opioids, about 25% use them chronically. Prescribing was mostly limited to moderate doses, with most veterans using opioids for approximately two months of the 12-month study period.
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Affiliation(s)
- Teresa J Hudson
- HSR&D, Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jacob T Painter
- HSR&D, Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
- Division of Pharmaceutical Outcome and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Laura E Gressler
- HSR&D, Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
- Division of Pharmaceutical Outcome and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Liya Lu
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - J Silas Williams
- HSR&D, Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
| | - Brenda M Booth
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Bradley C Martin
- Division of Pharmaceutical Outcome and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
| | - Mark J Edlund
- Behavioral and Urban Health Epidemiology Program, RTI International, Research Triangle Park, Durham, North Carolina
- Behavioral Health Services, St Luke’s Health System, Twin Falls, Idaho, USA
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Jang SH, Kwon YH. Central Pain Due to Traumatic Axonal Injury of the Spinothalamic Tract in Patients with Mild Traumatic Brain Injury. BRAIN & NEUROREHABILITATION 2018. [DOI: 10.12786/bn.2018.11.e7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Young Hyeon Kwon
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
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Abstract
The past 50 years have been a period of exciting progress in neuropsychological research on traumatic brain injury (TBI). Neuropsychologists and neuropsychological testing have played a critical role in these advances. This study looks back at three major scientific advances in research on TBI that have been critical in pushing the field forward over the past several decades: The advent of modern neuroimaging; the recognition of the importance of non-injury factors in determining recovery from TBI; and the growth of cognitive rehabilitation. Thanks to these advances, we now have a better understanding of the pathophysiology of TBI and how recovery from the injury is also shaped by pre-injury, comorbid, and contextual factors, and we also have increasing evidence that active interventions, including cognitive rehabilitation, can help to promote better outcomes. The study also peers ahead to discern two important directions that seem destined to influence research on TBI over the next 50 years: the development of large, multi-site observational studies and randomized controlled trials, bolstered by international research consortia and the adoption of common data elements; and attempts to translate research into health care and health policy by the application of rigorous methods drawn from implementation science. Future research shaped by these trends should provide critical evidence regarding the outcomes of TBI and its treatment, and should help to disseminate and implement the knowledge gained from research to the betterment of the quality of life of persons with TBI. (JINS, 2017, 23, 806-817).
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21
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Landefeld JC, Miaskowski C, Tieu L, Ponath C, Lee CT, Guzman D, Kushel M. Characteristics and Factors Associated With Pain in Older Homeless Individuals: Results From the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) Study. THE JOURNAL OF PAIN 2017; 18:1036-1045. [PMID: 28412229 PMCID: PMC5581208 DOI: 10.1016/j.jpain.2017.03.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/16/2017] [Accepted: 03/28/2017] [Indexed: 12/22/2022]
Abstract
Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0-10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4-3.7), arthritis (AOR: 4.8, 95% CI, 3.0-7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3-4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness. PERSPECTIVE This article describes the prevalence and factors associated with chronic pain in older homeless adults. Almost half report chronic pain, which was associated with PTSD, arthritis, and personal history of abuse. Clinicians should address chronic pain, trauma, and the associated mental health conditions in this high-risk population.
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Affiliation(s)
- John C Landefeld
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christine Miaskowski
- Department of Physiological Nursing, University of California, San Francisco, California
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christopher T Lee
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
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Irvine KA, Clark JD. Chronic Pain After Traumatic Brain Injury: Pathophysiology and Pain Mechanisms. PAIN MEDICINE 2017; 19:1315-1333. [DOI: 10.1093/pm/pnx153] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Karen-Amanda Irvine
- Veterans Affairs Palo Alto Health Care System, Anesthesiology Service, Palo Alto, California
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - J David Clark
- Veterans Affairs Palo Alto Health Care System, Anesthesiology Service, Palo Alto, California
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
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23
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Abou-El-Hassan H, Dia B, Choucair K, Eid SA, Najdi F, Baki L, Talih F, Eid AA, Kobeissy F. Traumatic brain injury, diabetic neuropathy and altered-psychiatric health: The fateful triangle. Med Hypotheses 2017; 108:69-80. [PMID: 29055405 DOI: 10.1016/j.mehy.2017.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 07/25/2017] [Accepted: 08/06/2017] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury is a detrimental medical condition particularly when accompanied by diabetes. There are several comorbidities going along with diabetes including, but not limited to, kidney failure, obesity, coronary artery disease, peripheral vascular disease, hypertension, stroke, neuropathies and amputations. Unlike diabetes type 1, diabetes type 2 is more common in adults who simultaneously suffer from other comorbid conditions making them susceptible to repetitive fall incidents and sustaining head trauma. The resulting brain insult exacerbates current psychiatric disorders such as depression and anxiety, which, in turn, increases the risk of sustaining further brain traumas. The relationship between diabetes, traumatic brain injury and psychiatric health constitutes a triad forming a non-reversible vicious cycle. At the proteomic and psychiatric levels, cellular, molecular and behavioral alterations have been reported with the induction of non-traumatic brain injury in diabetic models such as stroke. However, research into traumatic brain injury has not been systematically investigated. Thus, in cases of diabetic neuropathy complicated with traumatic brain injury, utilizing fine structural and analytical techniques allows the identification of key biological markers that can then be used as innovative diagnostics as well as novel therapeutic targets in an attempt to treat diabetes and its sequelae especially those arising from repetitive mild brain trauma.
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Affiliation(s)
- Hadi Abou-El-Hassan
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Batoul Dia
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khalil Choucair
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Stephanie A Eid
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Farah Najdi
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Lama Baki
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Farid Talih
- Department of Psychiatry, Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Assaad A Eid
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
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Seal KH, Bertenthal D, Barnes DE, Byers AL, Strigo I, Yaffe K. Association of Traumatic Brain Injury With Chronic Pain in Iraq and Afghanistan Veterans: Effect of Comorbid Mental Health Conditions. Arch Phys Med Rehabil 2017; 98:1636-1645. [DOI: 10.1016/j.apmr.2017.03.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/10/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
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Suri P, Stolzmann K, Iverson KM, Williams R, Meterko M, Yan K, Gormley K, Pogoda TK. Associations Between Traumatic Brain Injury History and Future Headache Severity in Veterans: A Longitudinal Study. Arch Phys Med Rehabil 2017; 98:2118-2125.e1. [PMID: 28483652 DOI: 10.1016/j.apmr.2017.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 03/29/2017] [Accepted: 04/09/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether traumatic brain injury (TBI) history is associated with worse headache severity outcomes. DESIGN Prospective cohort study. SETTING Department of Veterans Affairs (VA) outpatient clinics. PARTICIPANTS Veterans (N=2566) who completed a mail follow-up survey an average of 3 years after a comprehensive TBI evaluation (CTBIE). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The presence or absence of TBI, and TBI severity were evaluated by a trained clinician and classified according to VA/Department of Defense clinical practice guidelines. Headache severity was evaluated at both the baseline CTBIE assessment and 3-year follow-up using a 5-level headache score ranging from 0 ("none") to 4 ("very severe") based on headache-associated activity interference in the past 30 days. We examined associations of mild and moderate/severe TBI history, as compared to no TBI history, with headache severity in cross-sectional and longitudinal analyses, with and without adjustment for potential confounders. RESULTS Mean headache severity scores were 2.4 at baseline and 2.3 at 3-year follow-up. Mild TBI was associated with greater headache severity in multivariate-adjusted cross-sectional analyses (β [SE]=.61 [.07], P<.001), as compared with no TBI, but not in longitudinal analyses (β [SE]=.09 [.07], P=.20). Moderate/severe TBI was significantly associated with greater headache severity in both cross-sectional (β [SE]=.66 [.09], P<.001) and longitudinal analyses (β [SE]=.18 [.09], P=.04). CONCLUSIONS Headache outcomes are poor in veterans who receive VA TBI evaluations, irrespective of past TBI exposure, but significantly worse in those with a history of moderate/severe TBI. No association was found between mild TBI and future headache severity in veterans. Veterans with headache presenting for TBI evaluations, and particularly those with moderate/severe TBI, may benefit from further evaluation and treatment of headache.
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Affiliation(s)
- Pradeep Suri
- Division of Rehabilitation Care Services/Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Katherine M Iverson
- National Center for PTSD, VA Boston Healthcare System, Boston, MA; Department of Psychiatry, Boston University School of Medicine, Boston, MA
| | - Rhonda Williams
- Division of Rehabilitation Care Services/Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Mark Meterko
- Veterans Health Administration, Office of Performance Measurement, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Kun Yan
- Department of Physical Medicine and Rehabilitation, Northern California VA Healthcare System, Sacramento, CA
| | - Katelyn Gormley
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
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26
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Jang SH, Lee HD. Central pain due to spinothalamic tract injury caused by indirect head trauma following a pratfall. Brain Inj 2016; 30:933-6. [PMID: 27058675 DOI: 10.3109/02699052.2016.1146966] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES This study reports on patients who showed central pain due to injury of the spinothalamic tract (STT) caused by fall without direct head trauma. DESIGN Prospective study. PARTICIPANTS Two patients with mild traumatic brain injury (TBI) resulting from a fall were enrolled. Patient 1 was a 21-year-old female who had suffered a pratfall with no history of direct head trauma. She had begun to feel pain in both upper trunk and lower back and the left leg since ~ 5 days after onset: constant tingling and throbbing sensation with allodynia. Patient 2 was a 39-year-old male who had suffered a pratfall without direct head trauma. He had begun to feel pain in both arms and legs since ~ 4 days after the fall: constant tingling and pricking sensation without allodynia or hyperalgesia. RESULTS On diffusion tensor tractograhpy (DTT) of patient 1, partial tearing of the right STT was observed at the subcortical white matter. On DTT of patient 2, partial tearing at the subcortical white matter was observed in the right STT and partial narrowing at the subcortical white matter was observed in the left STT. CONCLUSIONS This study demonstrated injury of the STT in patients who suffered from central pain following a fall. The results suggest that minor indirect head trauma can cause traumatic axonal injury of the brain.
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Affiliation(s)
- Sung Ho Jang
- a Department of Physical Medicine and Rehabilitation , College of Medicine, Yeungnam University , Taegu , Republic of Korea
| | - Han Do Lee
- a Department of Physical Medicine and Rehabilitation , College of Medicine, Yeungnam University , Taegu , Republic of Korea
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27
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Xu H, Pi H, Ma L, Su X, Wang J. Incidence of Headache After Traumatic Brain Injury in China: A Large Prospective Study. World Neurosurg 2016; 88:289-296. [DOI: 10.1016/j.wneu.2015.12.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 01/03/2023]
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Jang SH, Kwon HG. Degeneration of an injured spinothalamic tract in a patient with mild traumatic brain injury. Brain Inj 2016; 30:1026-8. [PMID: 27029559 DOI: 10.3109/02699052.2016.1146961] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES This study reports on a patient who developed degeneration of an injured spinothalamic tract (STT) detected on diffusion tensor tractography (DTT) following mild traumatic brain injury (TBI). CASE DESCRIPTION A 56-year-old female had suffered from head trauma resulting from a pedestrian car accident. The patient did not experience loss of consciousness or post-traumatic amnesia and the patient's Glasgow Coma Scale score was 15. She had begun to feel pain in her left hand and foot at ~ 7 days after onset. The characteristics and severity of pain were as follows: constant tingling and pricking sensation without allodynia or hyperalgesia (Visual Analogue Scale score: 3~4). No specific focal lesion was observed on brain and spine MRI and an electromyography study showed no evidence of peripheral nerve injury or radiculopathy. At 6 months after onset, the central pain in the left hand and foot became aggravated, with a Visual Analogue Scale score of 6. RESULTS On 1-month DTT, partial tearing was observed in both STTs. In contrast, both partially torn STTs had become atrophy on 9-month DTT. CONCLUSIONS This study recommends further studies conducted on the prognosis (regeneration or degeneration) of injured STTs and on the effect of change of an injured STT on central pain.
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Affiliation(s)
- Sung Ho Jang
- a Department of Physical Medicine and Rehabilitation , College of Medicine, Yeungnam University , Daegu , Republic of Korea
| | - Hyeok Gyu Kwon
- a Department of Physical Medicine and Rehabilitation , College of Medicine, Yeungnam University , Daegu , Republic of Korea
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Nayiager T, Duckworth J, Pullenayegum E, Whitton A, Hollenberg R, Horsman J, Furlong W, Spitzer R, Barr R. Exploration of Morbidity in a Serial Study of Long-Term Brain Tumor Survivors: A Focus on Pain. J Adolesc Young Adult Oncol 2016; 4:129-36. [PMID: 26812665 DOI: 10.1089/jayao.2015.0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Children surviving brain tumors are frequently identified as having substantially decreased health-related quality of life (HRQL) in cross-sectional studies. This study explored the HRQL of a cohort of such survivors, who were recruited as adolescents and followed for a decade, in order to determine the trajectory of their morbidities. METHOD Children diagnosed between January 1, 1985, and December 31, 1998, more than 2 years from diagnosis (N = 40), were recruited in 2000/2001 (T1) aged 16.74 ± 4.23 years. Health Utilities Index questionnaires (HUI2/3) were completed in 2000/2001 and again at 5 years (T2) and 10 years (T3), with 37 and 25 participants then aged 21.54 ± 4.29 and 27.97 ± 4.07 years, respectively. In addition to study subjects, parental proxies completed questionnaires at T1 and T2, while study subjects selected proxies at T3. Single attributes (domains/dimensions) of HRQL and details of pain were analyzed. RESULTS Cognition was the attribute compromised most often (T1 = 66.7% of participants, T2 = 62.2%, T3 = 60.0%). Pain was also reported frequently (T1 = 35%, T2 = 25%, T3 = 52%), and at T3 correlated moderately with HUI2 sensation (0.77) and HUI3 vision (0.44), speech (0.51), and ambulation (0.50). The lower median utility score for pain at T3 than at T1/T2 was a clinically important difference. Severe pain was identified in the lower extremities, back, upper extremities, and abdomen. Morbidity was observed also in emotion (worry HUI2 and unhappiness HUI3), sensation, and vision. CONCLUSION Decreased HRQL in survivors of brain tumors in childhood is multifaceted. Pain is a prominent burden, along with morbidity in cognition, emotion, sensation, and vision. Further studies should explore pain and neurologic deficits, and potential opportunities for therapeutic intervention.
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Affiliation(s)
- Trishana Nayiager
- 1 Service of Hematology-Oncology, McMaster Children's Hospital , Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - JoAnn Duckworth
- 1 Service of Hematology-Oncology, McMaster Children's Hospital , Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Eleanor Pullenayegum
- 2 Child Health Evaluative Sciences, Hospital for Sick Children , Toronto, Ontario, Canada
| | - Anthony Whitton
- 3 Department of Radiation Oncology, Juravinski Cancer Centre, Hamilton Health Sciences , Hamilton, Ontario, Canada
| | - Robert Hollenberg
- 4 Service of Surgery, McMaster Children's Hospital , Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John Horsman
- 5 Health Utilities, Inc. , Dundas, Ontario, Canada
| | | | - Rachel Spitzer
- 6 Department of Obstetrics and Gynecology, Mount Sinai Hospital , Toronto, Ontario, Canada
| | - Ronald Barr
- 1 Service of Hematology-Oncology, McMaster Children's Hospital , Hamilton Health Sciences, Hamilton, Ontario, Canada .,7 Division of Hematology-Oncology, Department of Pediatrics, McMaster University , Hamilton, Ontario, Canada
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Stratton KJ, Hawn SE, Amstadter AB, Cifu DX, Walker WC. Correlates of pain symptoms among Iraq and Afghanistan military personnel following combat-related blast exposure. ACTA ACUST UNITED AC 2015; 51:1189-1202. [PMID: 25789376 DOI: 10.1682/jrrd.2014.04.0111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pain complaints are highly prevalent among military servicemembers and Veterans of the recent combat operations in Iraq and Afghanistan. The high comorbidity of pain with conditions such as posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) underscores the importance of a greater understanding of factors associated with complex polytraumatic injuries among military personnel. The present study aimed to identify correlates of current pain among 201 U.S. military personnel who reported at least one blast experience during combat deployment (age [mean +/– standard deviation]: 27.20 +/– 7.58 yr). Theoretically derived subsets of variables were analyzed in successive hierarchical regression models to determine correlates of self-reported pain symptoms. Preliminary models evaluated demographic features, medical and injury characteristics (e.g., TBI classification), psychosocial history (e.g., trauma exposure), and psychiatric variables. A final model was then derived, in which older age, possible or probable mild TBI, depression symptoms, and PTSD re-experiencing symptoms emerged as significant correlates of pain. The findings further the understanding of polytrauma symptoms among military personnel by identifying specific patient characteristics and comorbidity patterns related to pain complaints. Increased awareness of demographic, psychiatric, or medical factors implicated in pain will enhance comprehensive clinical assessment and intervention efforts.
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The Relation Between Injury of the Spinothalamocortical Tract and Central Pain in Chronic Patients With Mild Traumatic Brain Injury. J Head Trauma Rehabil 2015; 30:E40-6. [DOI: 10.1097/htr.0000000000000121] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mahmood S, Al-Thani H, El-Menyar A, Alani M, Al-Hassani A, Mathrdikkal S, Peralta R, Latifi R. Tramadol in traumatic brain injury: Should we continue to use it? J Anaesthesiol Clin Pharmacol 2015; 31:344-8. [PMID: 26330713 PMCID: PMC4541181 DOI: 10.4103/0970-9185.161670] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Tramadol is commonly used to treat moderate to moderately-severe pain in adults. We aimed to analyze the clinical relevance of tramadol use during weaning and extubation in patients with traumatic brain injury (TBI). Material and Methods: A retrospective observational study was conducted and included all the intubated TBI patients at the level I trauma center between 2011 and 2012. Data included patient's demographics, mechanism of injury (MOI), Glasgow Coma Scale (GCS), injury severity score, length of Intensive Care Unit (ICU) stay length of stay (LOS), agitation scale, analgesics, failure of extubation and tracheostomy. Patients were divided into two groups based on whether they received tramadol (Group 1) or not (Group 2) during ventilatory weaning. Chi-square and Student's t-tests were used for categorical and continuous variables; respectively. Logistic regression analysis was performed for predictors of agitation in ICU. Results: The study included 393 TBI patients; the majority (96%) was males with a mean age of 33.6 ± 14 years. The most common MOI were motor vehicle crash (39%), fall (29%) and pedestrian (17%). The associated injuries were mainly chest (35%) and abdominal (16%) trauma. Tramadol was administered in 51.4% of TBI patients. Tracheostomy was performed in 12.4% cases. Agitation was observed in 34.2% cases. Group 1 patients had significantly lower age (31.6 ± 12.4 vs. 35.7 ± 15.6; P = 0.005) and head AIS (3.5 ± 0.8 vs. 3.9 ± 0.9; P = 0.001) compared to Group 2. The incidence of agitation, ICU and hospital LOS were higher in Group 1. Failure of extubation and tracheostomy were reported more frequently in Group 1 (P = 0.001). On multivariate analysis, tramadol use was an independent predictor for agitation (adjusted odds ratio 21; P = 0.001), followed by low GCS. Conclusion: Patients with TBI who received tramadol are more likely to develop agitation, undergo tracheostomy and to have longer hospital LOS. Therefore, an extensive risk-benefit assessment would help to attain maximum efficacy of the drug in TBI patients.
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Affiliation(s)
- Saeed Mahmood
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Section of Trauma Surgery, HGH, Doha, Qatar ; Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Mushrek Alani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Saji Mathrdikkal
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Rifat Latifi
- Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar ; Department of Surgery, University of Arizona, Tucson, AZ, USA
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Combes RD. A critical review of anaesthetised animal models and alternatives for military research, testing and training, with a focus on blast damage, haemorrhage and resuscitation. Altern Lab Anim 2014; 41:385-415. [PMID: 24329746 DOI: 10.1177/026119291304100508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Military research, testing, and surgical and resuscitation training, are aimed at mitigating the consequences of warfare and terrorism to armed forces and civilians. Traumatisation and tissue damage due to explosions, and acute loss of blood due to haemorrhage, remain crucial, potentially preventable, causes of battlefield casualties and mortalities. There is also the additional threat from inhalation of chemical and aerosolised biological weapons. The use of anaesthetised animal models, and their respective replacement alternatives, for military purposes -- particularly for blast injury, haemorrhaging and resuscitation training -- is critically reviewed. Scientific problems with the animal models include the use of crude, uncontrolled and non-standardised methods for traumatisation, an inability to model all key trauma mechanisms, and complex modulating effects of general anaesthesia on target organ physiology. Such effects depend on the anaesthetic and influence the cardiovascular system, respiration, breathing, cerebral haemodynamics, neuroprotection, and the integrity of the blood-brain barrier. Some anaesthetics also bind to the NMDA brain receptor with possible differential consequences in control and anaesthetised animals. There is also some evidence for gender-specific effects. Despite the fact that these issues are widely known, there is little published information on their potential, at best, to complicate data interpretation and, at worst, to invalidate animal models. There is also a paucity of detail on the anaesthesiology used in studies, and this can hinder correct data evaluation. Welfare issues relate mainly to the possibility of acute pain as a side-effect of traumatisation in recovered animals. Moreover, there is the increased potential for animals to suffer when anaesthesia is temporary, and the procedures invasive. These dilemmas can be addressed, however, as a diverse range of replacement approaches exist, including computer and mathematical dynamic modelling of the human body, cadavers, interactive human patient simulators for training, in vitro techniques involving organotypic cultures of target organs, and epidemiological and clinical studies. While the first four of these have long proven useful for developing protective measures and predicting the consequences of trauma, and although many phenomena and their sequelae arising from different forms of trauma in vivo can be induced and reproduced in vitro, non-animal approaches require further development, and their validation and use need to be coordinated and harmonised. Recommendations to these ends are proposed, and the scientific and welfare problems associated with animal models are addressed, with the future focus being on the use of batteries of complementary replacement methods deployed in integrated strategies, and on greater transparency and scientific cooperation.
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Effect of lacosamide on structural damage and functional recovery after traumatic brain injury in rats. Epilepsy Res 2014; 108:653-65. [PMID: 24636248 DOI: 10.1016/j.eplepsyres.2014.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 01/31/2014] [Accepted: 02/01/2014] [Indexed: 11/23/2022]
Abstract
In a subgroup of patients, traumatic brain injury (TBI) results in the occurrence of acute epileptic seizures or even status epilepticus, which are treated with antiepileptic drugs (AEDs). Recent experimental data, however, suggest that administration of AEDs at the early post-injury phase can compromise the recovery process. The present study was designed to assess the profile of a novel anticonvulsant, lacosamide (Vimpat) on post-TBI structural, motor and cognitive outcomes. Moderate TBI was induced by lateral fluid-percussion injury in adult rats. Treatment with 0.9% saline or lacosamide (30 mg/kg, i.p.) was started at 30 min post-injury and continued at 8h intervals for 3d (total daily dose 90 mg/kg/d). Rats were randomly assigned to 4 treatment groups: sham-operated controls treated with vehicle (Sham-Veh) or lacosamide (Sham-LCM) and injured animals treated with vehicle (TBI-Veh) or lacosamide (TBI-LCM). As functional outcomes we tested motor recovery with composite neuroscore and beam-walking at 2, 7, and 15 d post-injury. Cognitive recovery was tested with the Morris water-maze at 12-14 d post-TBI. To assess the structural outcome, animals underwent magnetic resonance imaging (MRI) at 2 d post-TBI. At 16d post-TBI, rats were perfused for histology to analyze cortical and hippocampal neurodegeneration and axonal damage. Our data show that at 2 d post-TBI, both the TBI-Veh and TBI-LCM groups were equally impaired in neuroscore. Thereafter, motor recovery occurred similarly during the first week. At 2 wk post-TBI, recovery of the TBI-LCM group lagged behind that in the TBI-VEH group (p<0.05). Performance in beam-walking did not differ between the TBI-Veh and TBI-LCM groups. Both TBI groups were similarly impaired in the Morris water-maze at 2 wk post-TBI. MRI and histology did not reveal any differences in the cortical or hippocampal damage between the TBI-Veh and TBI-LCM groups. Taken together, acute treatment with LCM had no protective effects on post-TBI structural or functional impairment. Composite neuroscore in the TBI-LCM group lagged behind that in the TBI-Veh group at 15 d post-injury, but no compromise was found in other indices of post-TBI recovery in the LCM treated animals.
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Lucas S, Hoffman JM, Bell KR, Dikmen S. A prospective study of prevalence and characterization of headache following mild traumatic brain injury. Cephalalgia 2013; 34:93-102. [PMID: 23921798 DOI: 10.1177/0333102413499645] [Citation(s) in RCA: 204] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild TBI (mTBI). METHODS We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache. RESULTS Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods. CONCLUSIONS Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.
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Affiliation(s)
- Sylvia Lucas
- Department of Neurology, University of Washington, Seattle, WA, USA
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Weyer Jamora C, Schroeder SC, Ruff RM. Pain and mild traumatic brain injury: the implications of pain severity on emotional and cognitive functioning. Brain Inj 2013; 27:1134-40. [PMID: 23895398 DOI: 10.3109/02699052.2013.804196] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE The aim of this study was to examine the effect of high chronic pain on (a) neuropsychological test performance and (b) self-reported emotional complaints in persons suffering from Postconcussional Disorders (PCD) after a mild traumatic brain injury (TBI). RESEARCH DESIGN A two-group comparative research design was employed. METHODS AND PROCEDURE An outpatient sample of 66 patients with mild TBI and PCD using the Ruff Neurobehavioural Inventory (RNBI) and a neuropsychological test battery. MAIN OUTCOMES AND RESULTS According to ANOVAs, no significant between-group differences were found on neuropsychological test performances; however, the high pain group had significantly more emotional residuals; particularly elevated on the RNBI were the Anger and Aggression, Anxiety, Depression and Paranoia and Suspicion sub-scales. Furthermore, an ANOVA found participants of the high pain group reporting significantly higher impairments on the RNBI Cognitive, Physical and Quality-of-Life composite scores and several RNBI sub-scales compared to their pre-morbid functioning. CONCLUSIONS High chronic pain exacerbates the emotional aspect of PCD and, therefore, should be given special observance in treatment settings.
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Bosco MA, Murphy JL, Clark ME. Chronic pain and traumatic brain injury in OEF/OIF service members and Veterans. Headache 2013; 53:1518-22. [PMID: 23848062 DOI: 10.1111/head.12172] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2013] [Indexed: 12/14/2022]
Abstract
The co-occurrence of chronic pain and traumatic brain injury (TBI) are 2 of the most common concerns among the Operations Enduring Freedom and Iraqi Freedom population and present unique challenges for evaluation and treatment. Previous research suggests that almost half the cohort report clinically significant pain, while up to 1 in 4 experiences some form of TBI. There is limited information regarding how TBI affects the presence and course of pain, and how pain impacts TBI and its symptoms. The present paper provides an overview of the range and degree of TBIs as well as a brief summary of current knowledge regarding the interaction between chronic pain and TBI, particularly in light of the numerous variables impacting it. Information on ways to best assess for and treat pain in the TBI population, including in those with multiple system injuries or associated affective symptoms, is provided. In addition, several innovative approaches for addressing the needs of this complex cohort of patients are described, which may stimulate further research and clinical innovation for this important subgroup.
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Giustini A, Pistarini C, Pisoni C. Traumatic and nontraumatic brain injury. NEUROLOGICAL REHABILITATION 2013; 110:401-9. [DOI: 10.1016/b978-0-444-52901-5.00034-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Defrin R, Gruener H, Schreiber S, Pick CG. Quantitative somatosensory testing of subjects with chronic post-traumatic headache: Implications on its mechanisms. Eur J Pain 2012; 14:924-31. [DOI: 10.1016/j.ejpain.2010.03.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 01/26/2010] [Accepted: 03/04/2010] [Indexed: 11/28/2022]
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Peng Q, Park HS, Shah P, Wilson N, Ren Y, Wu YN, Liu J, Gaebler-Spira DJ, Zhang LQ. Quantitative evaluations of ankle spasticity and stiffness in neurological disorders using manual spasticity evaluator. ACTA ACUST UNITED AC 2011; 48:473-81. [PMID: 21674395 DOI: 10.1682/jrrd.2010.04.0053] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spasticity and contracture are major sources of disability in people with neurological impairments that have been evaluated using various instruments: the Modified Ashworth Scale, tendon reflex scale, pendulum test, mechanical perturbations, and passive joint range of motion (ROM). These measures generally are either convenient to use in clinics but not quantitative or they are quantitative but difficult to use conveniently in clinics. We have developed a manual spasticity evaluator (MSE) to evaluate spasticity/contracture quantitatively and conveniently, with ankle ROM and stiffness measured at a controlled low velocity and joint resistance and Tardieu catch angle measured at several higher velocities. We found that the Tardieu catch angle was linearly related to the velocity, indicating that increased resistance at higher velocities was felt at further stiffer positions and, thus, that the velocity dependence of spasticity may also be position-dependent. This finding indicates the need to control velocity in spasticity evaluation, which is achieved with the MSE. Quantitative measurements of spasticity, stiffness, and ROM can lead to more accurate characterizations of pathological conditions and outcome evaluations of interventions, potentially contributing to better healthcare services for patients with neurological disorders such as cerebral palsy, spinal cord injury, traumatic brain injury, and stroke.
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Affiliation(s)
- Qiyu Peng
- Rehabilitation Institute of Chicago, Chicago, IL 60611, USA
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Hoffman JM, Lucas S, Dikmen S, Braden CA, Brown AW, Brunner R, Diaz-Arrastia R, Walker WC, Watanabe TK, Bell KR. Natural history of headache after traumatic brain injury. J Neurotrauma 2011; 28:1719-25. [PMID: 21732765 DOI: 10.1089/neu.2011.1914] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p<0.001) and females (p<0.01) were significantly more likely to report headache. The incidence of headache had no relation to TBI severity (p=0.67). Overall, headache is common in the first year after TBI, independent of the severity of injury range examined in this study. Use of the International Classification of Headache Disorders criteria requiring onset of headache within 1 week of injury underestimates rates of post-traumatic headache. Better understanding of the natural history of headache including timing, type, and risk factors should aid in the design of treatment studies to prevent or reduce the chronicity of headache and its disruptive effects on quality of life.
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Affiliation(s)
- Jeanne M Hoffman
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington 98195-6490, USA.
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Crooks CY, Zumsteg JM, Bell KR. Traumatic Brain Injury: A Review of Practice Management and Recent Advances. Phys Med Rehabil Clin N Am 2007; 18:681-710, vi. [DOI: 10.1016/j.pmr.2007.06.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ofek H, Defrin R. The characteristics of chronic central pain after traumatic brain injury. Pain 2007; 131:330-340. [PMID: 17689190 DOI: 10.1016/j.pain.2007.06.015] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2007] [Revised: 06/11/2007] [Accepted: 06/15/2007] [Indexed: 10/23/2022]
Abstract
Central pain following traumatic brain injury (TBI) has not been studied in depth. Our purpose was to conduct a systematic study of patients with TBI suffering from chronic central pain, and to describe the characteristics of the central pain. Groups were TBI patients with (TBIP) and without central pain (TBINP) and healthy controls. TBI patients with other pain mechanisms were excluded from the study. Participants underwent quantitative somatosensory testing in the painful and pain-free body regions. Thresholds for warmth, cold, heat-pain, touch and graphesthesia were measured and pathologically evoked pain (allodynia, hyperpathia and wind-up pain) evaluated. Chronic pain was mapped and characterized. Chronic pain developed at a relatively late onset (6.6+/-9 months) was almost exclusively unilateral and reported as pricking, throbbing and burning. Although both TBIP and TBINP exhibited a significant reduction in thermal and tactile sensations compared to controls, thermal sensations in the painful regions of TBIP were significantly more impaired than pain-free regions in the same patients (p<0.01) and in TBINP (p<0.01). Painful regions also exhibited very high rates of allodynia, hyperpathia and exaggerated wind-up. The characteristics of the chronic pain resembled those of other central pain patients although TBIP displayed several unique features. The sensory profile indicated that damage to the pain and temperature systems is a necessary but not sufficient condition for the development of chronic central pain following TBI. Neuronal hyperexcitability may be a contributing factor to the chronic pain.
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Affiliation(s)
- Hadas Ofek
- Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv 69978, Israel Loewenstein Hospital Rehabilitation Center, Raanana, Israel
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Abstract
For the patient who has sustained traumatic brain injury (TBI), understanding the problem and listening to and believing the patient are prerequisites to treating pain. Because the information provided may be limited, communication skills problematic, and consistency variable, the challenge of treating individuals with TBI and pain can be daunting. Most painful conditions after TBI involve the musculoskeletal system; however, in conditions that are neurologically based, a careful and well-organized neurologic examination can be helpful to direct one's attention toward ordering the appropriate tests and treatments. The primary focus for helping patients with pain involves not only understanding the problem and assisting with symptom relief but also providing the opportunity to improve their functioning, physically and cognitively.
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