Understanding pain after traumatic brain injury: impact on community participation

Chronic pain after traumatic brain injury: a collaborative care approach

Introduction

Chronic pain is common after traumatic brain injury (TBI), frequently limits daily activities, and is associated with negative outcomes such as decreased community participation. Despite the negative impact of chronic pain, few people with TBI receive effective treatment. This paper describes a collaborative care (CC) intervention, TBI Care, adapted specifically to treat chronic pain in people living with TBI, emphasizing expert clinician input, cognitive behavioral therapy (CBT) techniques, and other non-pharmacological approaches for decreasing pain interference.

Methods

79 participants engaged in the CC intervention from two academic medical rehabilitation clinics with weekly assessments of pain intensity, interference, and medication use. Participant feedback on the intervention was gathered by interview with the care manager (CM) at the last treatment session and/or booster session. Provider feedback was gathered by a confidential survey post intervention.

Results

Ninety percent of participants received at least 11 of the target 12 sessions with a care manager (CM), the majority occurring over the phone. Participants endorsed an average of 7 pain locations. All participants received pain education, skills in self-monitoring, goal setting/behavioral activation and relaxation training. Pain interference scores (impact on activity and enjoyment), tracked weekly by the CM, significantly decreased across sessions. 89% of participants received recommendations for CBT skills, 65% received referrals for additional treatments targeting pain interference, and 43% received care coordination. 75% of participants reported 6 or more medications/supplements at both the first and last session, with changes recommended primarily for headache treatment. Feedback from participants and providers was positive.

Discussion

TBI Care, a novel patient-centered CC approach, was flexibly delivered, tailored to the needs of those living with TBI and chronic pain, with a high level of participant engagement, and satisfaction among participants and providers. This approach, prioritizing pain self-management strategies and other non-pharmacological approaches, along with optimizing pharmacological treatment, led to significant reductions in self-reported pain interference and intensity during the intervention. Using a CC model in TBI is feasible and successfully improved access to evidence-based treatments for chronic pain as well as outcomes for pain interference and intensity.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT03523923.

Headache management in traumatic brain injury

Traumatic brain injury (TBI) is estimated to rank as the third most important disease burden worldwide. About 60% of the survivors develop chronic headaches and visual symptoms, and the long-term management of headaches in these patients is controversial. Importantly, the care pathway of most patients is fragmented, complicating conclusive headache management. Here we review the epidemiology and aetiology of post traumatic headaches (PTH), discuss the diagnostic work up and summarise the acute and long-term management.

Management of Pain and Headache After Traumatic Brain Injury

This article will identify common causes of pain following traumatic brain injury (TBI), discuss current treatment strategies for these complaints, and help tailor treatments for both acute and chronic settings. We will also briefly discuss primary and secondary headache disorders, followed by common secondary pain disorders that may be related to trauma.

Collaborative Care for Chronic Pain After Traumatic Brain Injury: A Randomized Clinical Trial

Importance

Chronic pain after traumatic brain injury (TBI) is prevalent and associated with poor outcomes. By providing multidisciplinary care through expert consultation, a collaborative care (CC) treatment approach may reduce pain interference.

Objective

To compare CC with usual care (UC) in decreasing pain interference.

Design, Setting, and Participants

This randomized clinical trial was conducted from July 2018 through April 2021 at 2 hospital-based academic rehabilitation medicine clinics in Seattle, Washington. Participants included adults with mild-to-severe TBI (at least 6 months before enrollment) and chronic pain. Data analysis was performed from March 30, 2022, to August 30, 2023.

Intervention

The CC intervention (called TBI Care) included up to 12 in-person or telephone visits over 16 weeks with a care manager (CM) who provided person-centered cognitive behavioral treatment. The CM met weekly with members of the expert team to review participants and discuss recommendations to optimize treatment.

Main Outcomes and Measures

The primary outcome was pain interference on the Brief Pain Inventory at treatment conclusion (4 months after randomization). Secondary outcomes included pain interference at 8 months; pain severity; symptoms of depression, anxiety, and sleep disturbance; pain-related emergency department visits; community participation; and participant satisfaction. Linear mixed-effects regression was used for analysis.

Results

A total of 1379 individuals were screened for eligibility, and 158 were randomized (79 to CC and 79 to UC). The participants were mostly women (92 participants [58%]) with a mean (SD) age of 46.8 (13.2) years and a mean (SD) of 15.3 (3.0) years of education. TBI occurred a mean (SD) of 4.0 (5.9) years (median [IQR], 1.9 [0.8-4.5] years) before enrollment. All TBI severities were included, and of 149 participants for whom TBI severity was known, the majority (97 participants [65%]) had mild TBI. In the CC group, 71 participants (90%) completed at least 11 sessions, and, at 4 months, this group had significantly lower pain interference scores compared with the UC group (mean [SD], 3.46 [2.17] vs 5.03 [2.28]). This difference was maintained at 8 months after randomization, with mean (SD) TBI care pain interference scores of 3.61 (2.22) for CC vs 4.68 (2.51) for UC. At 4 months, there was significantly lower pain severity in the CC group vs UC group (mean [SD] score, 3.63 [1.95] vs 4.90 [1.96]), as well as symptoms of depression (mean [SD] score, 8.07 [5.34] vs 11.31 [6.37]) and anxiety (mean [SD], 6.20 [5.17] vs 9.58 [6.00]). Satisfaction with pain treatment (mean [SD] score, 2.99 [1.23] vs 2.52 [1.25]), clinical care (mean [SD] score, 3.28 [1.00] vs 2.84 [1.26]), and overall health care (mean [SD] score, 3.25 [0.88] vs 2.82 [1.00]) were significantly higher in the CC group vs the UC group; global impression of change was significantly lower in the CC group vs the UC group (mean [SD] score, 2.74 [1.02] vs 3.47 [1.26]) (lower scores denote a better impression of change).

Conclusions and Relevance

In this randomized clinical trial of CC compared with UC for patients with TBI, CC was effective at reducing pain interference and was sustained at 8-month follow-up. Further research is needed to examine the implementation and cost-effectiveness of CC for TBI in other health care settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT03523923.

Associations of Chronic Pain With Psychosocial Outcomes After Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

To examine the differences in participation, life satisfaction, and psychosocial outcomes among individuals with traumatic brain injury (TBI) endorsing current, past, or no chronic pain.

SETTING

Community.

PARTICIPANTS

Three thousand eight hundred four TBI Model Systems participants 1 to 30 years of age postinjury classified into 1 of 3 groups based on their pain experience: current pain, past pain, no pain completed a Pain Survey at their usual follow-up appointment which on average was approximately 8 years postinjury.

DESIGN

Multisite, cross-sectional observational cohort study.

MAIN OUTCOME MEASURES

Sociodemographic and injury characteristics and psychosocial outcomes (ie, satisfaction with life, depression, anxiety, posttraumatic stress disorder [PTSD], sleep quality, community participation).

RESULTS

Persons with current chronic pain demonstrated higher scores on measures of PTSD, anxiety, and depression, and the lower scores on measures of sleep quality, community participation and satisfaction with life. Those with resolved past pain had mean scores for these outcomes that were all between the current and no chronic pain groups, but always closest to the no pain group. After adjusting for sociodemographic and function in multivariate analysis, having current chronic pain was associated with more negative psychosocial outcomes. The largest effect sizes (ES; in absolute value) were observed for the PTSD, depression, anxiety, and sleep quality measures (ES = 0.52-0.81) when comparing current pain to past or no pain, smaller ES were observed for life satisfaction (ES = 0.22-0.37) and out and about participation (ES = 0.16-0.18). When comparing past and no pain groups, adjusted ES were generally small for life satisfaction, PTSD, depression, anxiety, and sleep quality (ES = 0.10-0.23) and minimal for participation outcomes (ES = 0.02-0.06).

CONCLUSIONS

Chronic pain is prevalent among individuals with TBI and is associated with poorer psychosocial outcomes, especially for PTSD, depression, anxiety, and sleep disturbance. The results from this study highlight the presence of modifiable comorbidities among those with chronic pain and TBI. Persons who experience persistent pain following TBI may be at greater risk for worse psychosocial outcomes.

Characterization and Treatment of Chronic Pain After Traumatic Brain Injury-Comparison of Characteristics Between Individuals With Current Pain, Past Pain, and No Pain: A NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

To estimate the prevalence of chronic pain after traumatic brain injury (TBI) and identify characteristics that differ from those without chronic pain.

SETTING

Community.

PARTICIPANTS

A total of 3804 TBI Model Systems (TBIMS) participants who completed the Pain Survey at TBIMS follow-up.

DESIGN

A multisite, cross-sectional observational cohort study.

MAIN OUTCOME MEASURES

Functional outcomes, pain experience, and treatment.

RESULTS

46% reported current chronic pain, 14% reported past (post-injury) chronic pain, and 40% reported no chronic pain. Bivariate differences in sociodemographic and injury characteristics between the 3 pain groups were generally small in effect size, reflecting little clinical difference. However, medium effect sizes were seen for all functional outcomes, such that individuals with current chronic pain had worse functional outcomes compared with individuals in the past pain or no pain groups. Treatment utilization rates were higher for individuals with current chronic pain compared with past pain, with medical treatments being most frequently utilized. Individuals with past pain perceived more improvement with treatment than did those with current chronic pain as represented by a large effect size.

CONCLUSIONS

Chronic pain affects approximately 60% of those living with TBI. The implications of chronic pain for functional outcomes support inclusion of pain metrics in prognostic models and observational studies in this population. Future research is needed to proactively identify those at risk for the development of chronic pain and determine the efficacy and access to pain treatment.

Pre-Trauma Pain Is the Strongest Predictor of Persistent Enhanced Pain Patterns after Severe Trauma: Results of a Single-Centre Retrospective Study

Background and Objectives: Traumatic injuries are a significant public health issue worldwide, with persistent enhanced pain being a common complication following severe trauma. Persistent and chronic pain can have a profound impact on patients' quality of life, affecting physical, emotional, and social functioning. This study aimed to investigate the pain patterns of trauma patients before and after severe trauma, and identify the predictors of persisting pain after injury. Materials and Methods: A total of 596 patients of a level-one trauma centre with severe trauma were included in this study. The Trauma Outcome Profile Scale was used to assess pain severity before and after trauma, and a logistic regression analysis was performed to determine the most significant predictors of relevant pain after severe trauma. Results: The mean age of the included patients was 48.2 years, and 72% were males. The most frequent cause of injury was traffic accidents, and the mean Injury Severity Score was 17.6. Nearly half of the patients experienced reduced pain-related quality of life after trauma, with persisting pain predominantly occurring in the neck, spine, shoulder, pelvis, hip, knee, and feet. Even minor injuries led to increased pain scores. Preexisting pain before injury (OR: 5.43; CI: 2.60-11.34), older age (OR: 2.09, CI: 1.22-3.27), female gender (OR: 1.08, CI: 0.73-1.59), and high injury severity (OR: 1.80, CI: 1.20-2.69) were identified as significant predictors of enhanced pain. Conclusions: These findings highlight the importance of considering pre-existing pain, body area, and injury severity in assessing the risk of persistent pain in trauma patients.

Usability of a two-way personalized mobile trainer system in a community-based exercise program for adults with chronic traumatic brain injury

OBJECTIVE

To examine the usability of an Apple Watch-based, two-way Personalized Mobile Trainer (PMT) in community-based exercise programs for individuals with chronic traumatic brain injury (cTBI).

METHODS

This is a prospective pilot study. Twenty participants with cTBI aged 46-73 were enrolled in a 3-month individualized exercise program. After one in-person training session on PMT and exercise program, participants were prescribed either aerobic exercise training (AET) or stretching and toning (SAT) performed at home. The PMT was used to remotely deliver updated exercise prescription, track exercise progress, and communicate with the participants. The primary outcome was compliance with the exercise programs.

RESULTS

All the participants completed the assigned exercise program with an average compliance of 76%. Nineteen (95%) participants were able to use the PMT properly during exercise sessions. After 3 months of training, the AET trended toward maintaining exercise endurance when compared with the SAT group (0.3% vs -4%, p = 0.14) with a medium effect size of 0.43.

CONCLUSION

Using the PMT system to support and track exercise in community-based exercise programs is feasible. The PMT may promote compliance with the training program but testing its effectiveness with larger trials is warranted.

Physical and Functional Impairment Among Older Adults With a History of Traumatic Brain Injury

OBJECTIVES

To examine the association of lifetime history of traumatic brain injury (TBI) with later-life physical impairment (PI) and functional impairment (FI) and to evaluate the impact of neurobehavioral symptoms that frequently co-occur with TBI on these relations.

PARTICIPANTS

A total of 1148 respondents to the 2014 Wave of the Health and Retirement Study, a nationally representative survey of older community-dwelling adults, randomly selected to participate in a TBI exposure survey. They reported no prior TBI (n = 737) or prior TBI (n = 411).

DESIGN

Cross-sectional survey study.

MAIN MEASURES

Physical impairment (self-reported difficulty with ≥1 of 8 physical activities); FI (self-reported difficulty with ≥1 of 11 activities of daily living); self-reported current neurobehavioral symptoms (pain, sleep problems, depression, subjective memory impairment); The Ohio State University TBI Identification Method (OSU-TBI-ID)-short form.

ANALYSES

Stepwise logistic regression models ([1] unadjusted; [2] adjusted for demographics and medical comorbidities; [3] additionally adjusted for neurobehavioral symptoms) compared PI and FI between TBI groups.

RESULTS

Traumatic brain injury-exposed (mean: 33.6 years postinjury) respondents were younger, less likely to be female, and reported more comorbidities and neurobehavioral symptoms. Although TBI was significantly associated with increased odds of PI and FI in unadjusted models and models adjusted for demographics/comorbidities (adjusted odds ratio, 95% confidence interval: PI 1.62, 1.21-2.17; FI 1.60, 1.20-2.14), this association was no longer statistically significant after further adjustment for neurobehavioral symptoms.

CONCLUSION

History of TBI is associated with substantial PI and FI among community-dwelling older adults. Further research is warranted to determine whether aggressive management of neurobehavioral symptoms in this population may mitigate long-term PI and FI in this population.

Scoping Review of Opioid Use After Traumatic Brain Injury

OBJECTIVE

To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI).

DATA SOURCES

The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings.

RESULTS

Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder.

CONCLUSIONS

Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.

Addressing Pain for a Proper Rehabilitation Process in Patients With Severe Disorders of Consciousness

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.

Incidence (2008-2015) of post-traumatic headaches in United States military personnel

Objective: To conduct a descriptive transversal study to evaluate the incidence and demographic characteristics of post-traumatic headache using data from the Defense Medical Epidemiology Database.Methods: A retrospective cohort study was conducted of data from 2008 to 2015 based on the International Classification of Diseases codes for both acute and chronic post-traumatic headache.Results: A total of 17,010 new cases of post-traumatic headaches were diagnosed among active duty military personnel. Reported incidence rates of post-traumatic headaches in the military increased 29-fold over the timeframe analyzed. Males enlisted in the Army were more likely to be diagnosed with post-traumatic headaches than females (O/E = 0.76), other branches, and officers.Conclusion: Findings of this study indicate that there is a significant incidence of post-traumatic headaches in the U.S. military. However, the incidence rates of post-traumatic headaches in the military are much lower than what was expected considering the number of traumatic brain injuries in the United States military reported by the Department of Defense for the same period. Additional research is needed to further evaluate these differences and the impact of PTHs on military personnel.

Is Helping Really Helping? Health-Related Quality of Life after TBI Predicting Caregiver Depression Symptom Trajectories in Latin America

Previous research connecting health-related quality of life (HRQoL) in people with traumatic brain injury (TBI) and caregiver mental health has primarily been conducted cross-sectionally in the U.S. and Western Europe. This study, therefore, examined how HRQoL in individuals immediately after their TBI predicts longitudinal caregiver depression symptom trajectories in Latin America. A sample of 109 patients with an acute TBI and 109 caregivers (total n = 218) was recruited from three hospitals in Mexico City, Mexico, and in Cali and Neiva, Colombia. TBI patients reported their HRQoL while they were still in hospital, and caregivers reported their depression symptoms at the same time and at 2 and 4 months later. Hierarchal linear models (HLM) found that caregiver depression symptom scores decreased over time, and lower patient mental health and pain-related quality of life at baseline (higher pain) predicted higher overall caregiver depression symptom trajectories across the three time points. These findings suggest that in Latin America, there is an identifiable relationship between psychological and pain-related symptoms after TBI and caregiver depression symptom outcomes. The results highlight the importance of early detection of caregiver mental health needs based in part upon patient HRQoL and a culturally informed approach to rehabilitation services for Latin American TBI caregivers.

Associations between frequent pain or headaches and neurobehavioral symptoms by gender and TBI severity

Objective: To investigate differences in frequent pain or headaches and associated neurobehavioral symptoms among men, women, and transgender individuals with and without a history of traumatic brain injury (TBI).Setting: CommunityParticipants: English and Spanish-speaking adults (n = 2,862) with and without self-reported TBIDesign: Cross-sectional studyMain Measures: Behavioral Assessment Screening Tool (BAST) subscales for Negative Affect, Substance Abuse, Executive Function, Fatigue, Impulsivity, and one item for experiencing "frequent pain or headache."Results: Women reported more pain than men. Women with a mild TBI (mTBI) more often reported frequent headaches/pain than woman in general or those with mTBI alone. Women reporting frequent headache/pain reported more negative affect and fatigue than men with comparable TBI history. Individuals identifying as transgender/other without TBI had higher negative affect and fatigue than both men and women without TBI. Individuals with mTBI and frequent headache/pain reported more executive function problems than those with mTBI without headache/pain. Pain and moderate/severe TBI were associated with more executive function problems in men and women, but more so for women.Conclusion: Results suggest frequent headache/pain may differ between genders, particularly after mTBI. Pain, fatigue, executive function, and negative affect may be especially important in women's recovery from TBI.

A Scoping Review of Predictors of Community Integration Following Traumatic Brain Injury: A Search for Meaningful Associations

OBJECTIVE

The purpose of this scoping review was to identify predictors of community integration for adults with traumatic brain injury.

DATA SOURCES

We searched the PubMed and PsycINFO databases and reviewed references of included studies. We selected studies exploring multiple components of community integration, including instrumental activities of daily living, leisure activities, and social activities. A total of 53 studies were included.

DATA EXTRACTION

We extracted data on sample size and sample characteristics (stage of injury and recovery, severity) and examined predictor variables, outcome measures for community integration, and significant findings, reported as correlations.

DATA SYNTHESIS

We found that the predictors of community integration fell into 4 categories: demographics, injury characteristics, disability and impairments, and environmental factors. There was large variability in reported relationships for demographics (r = 0.01-0.43), injury characteristics (r = 0.01-0.58), disability/functional impairments (r = 0.003-0.98) and environmental factors (r = 0.11-0.58). Cognition, disability, mobility/physical functioning, mood, social support, and length of posttraumatic amnesia had the strongest relationships with community integration outcomes.

CONCLUSIONS

Strategies for the management of cognitive, physical, and emotional functioning, and building and training a strong support system, may facilitate community integration outcomes. Additional work is warranted to further explore the discrepancies found among studies.

Disruption of periaqueductal grey-default mode network functional connectivity predicts persistent post-traumatic headache in mild traumatic brain injury

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.

Telephone-delivered cognitive behavioral therapy for veterans with chronic pain following traumatic brain injury: Rationale and study protocol for a randomized controlled trial study

BACKGROUND AND OBJECTIVES

Chronic pain is a highly prevalent and potentially disabling condition in Veterans who have had a traumatic brain injury (TBI) and access to non-pharmacological pain treatments such as cognitive behavioral therapy is limited and variable. The purpose of this randomized controlled trial (RCT) is to evaluate the efficacy of a telephone-delivered cognitive behavioral therapy (T-CBT) for pain in Veterans with a history of TBI.

METHODS

Veterans with a history of TBI and chronic pain of at least six months duration (N = 160) will be randomized to either T-CBT or a telephone-delivered pain psychoeducational active control condition (T-Ed). The eight-week T-CBT intervention builds on other efficacious CBT interventions for chronic pain in the general population but is novel in that it is conducted via telephone and adapted for Veterans with a history of TBI. Outcome variables will be collected pre, mid-, and post-treatment, and 6 months following randomization (follow-up).

PROJECTED OUTCOMES

In addition to evaluating the effects of the interventions on pain intensity (primary outcome), this study will determine their effects on pain interference, sleep, depression, and life satisfaction. We will also examine potential moderators of treatment outcomes such as cognition, PTSD, and alcohol and drug use. This non-pharmacologic one-on-one therapeutic intervention has the potential to reduce pain and pain-related dysfunction, improve access to care, and reduce barriers associated with geography, finances, and stigma, without the negative effects on physical and cognitive performance and potential for addiction as seen with some pharmacologic treatments for pain. This trial is registered at ClinicalTrials.gov, protocol NCT01768650.

The effects of post-traumatic depression on cognition, pain, fatigue, and headache after moderate-to-severe traumatic brain injury: a thematic review

BACKGROUND

Post-traumatic depression (PTD) is one of the most common secondary complications to develop after moderate-to-severe traumatic brain injury (TBI). However, it rarely manifests singularly, and often co-occurs with other common TBI impairments.

OBJECTIVE

The objective of this thematic review is to evaluate studies examining the relationships between PTD and cognition, fatigue, pain, and headache among individuals with moderate-to-severe TBI.

RESULTS

We reviewed 16 studies examining the relationship between PTD and cognition (five articles), fatigue (five articles), pain (four articles), and headache (two articles). Two studies failed to identify the significant associations between PTD and neuropsychological test performance, while one study found a positive association. Two other studies found that early PTD was associated with later executive dysfunction. Studies on fatigue suggest it is a cause, not consequence, of PTD. Individuals with PTD tended to report more pain than those without PTD. Studies examining relationships between PTD and post-traumatic headache were equivocal.

CONCLUSIONS

Studies evaluating the effects of PTD on common TBI impairments have yielded mixed results. Evidence suggests PTD precedes the development of executive dysfunction, and a strong link exists between fatigue and PTD, with fatigue preceding PTD. Future prospective studies evaluating PTD relationships to pain and headache are warranted to elucidate causality.

Predictors for Depressive Mood in Geriatric Patients After Traumatic Brain Injury: A Retrospective Cross-Sectional Study

Objective

To identify predictors for depressive mood in geriatric patients after traumatic brain injury (TBI).

Methods

A retrospective review of patients' medical charts was performed in TBI patients who were older than 60 years and referred to the Department of Rehabilitation Medicine at Severance Hospital in 2002–2016. The patients were classified into two groups based on the Geriatric Depression Scale (GDS): non-depressive group (0≤GDS≤16) and depressive group (17≤GDS≤30). Data was collected on demographic, socioeconomic, comorbidities, and trauma-related factors, as well as the pathophysiology of TBI, localization of lesion, post-traumatic complications, functional level, and cognitive and linguistic function. Significant variables from univariate analysis were analyzed using logistic regression.

Results

Forty-two patients were included, of whom 64.3% displayed a depressive mood. Patients in the depressive group had higher comorbidity scores (p=0.03), lower Functional Independence Measure (FIM) totals (p=0.03) and FIM motor (p=0.03) scores, higher modified Rankin Scale scores (p=0.04), and frequently had a bilateral or left side brain lesion (p=0.002). Higher comorbidity scores (odds ratio [OR], 1.764; 95% confidence interval [CI], 1.047–2.971), bilateral lesions (OR, 13.078; 95% CI, 1.786–95.780), and left side lesions (OR, 46.074; 95% CI, 3.175–668.502) were independently associated with a depressive mood in the multiple logistic regression analysis.

Conclusion

The risk of depressive mood in geriatric patients after TBI is associated with comorbidity, functional limitation, and the horizontal distribution of brain lesions. The most significant determining factors were comorbidity and the horizontal distribution of brain lesions. Early detection of risk factors is important to prevent and manage depressive mood in geriatric patients after TBI.

Mild closed head traumatic brain injury-induced changes in monoamine neurotransmitters in the trigeminal subnuclei of a rat model: mechanisms underlying orofacial allodynias and headache

Our recent findings have demonstrated that rodent models of closed head traumatic brain injury exhibit comprehensive evidence of progressive and enduring orofacial allodynias, a hypersensitive pain response induced by non-painful stimulation. These allodynias, tested using thermal hyperalgesia, correlated with changes in several known pain signaling receptors and molecules along the trigeminal pain pathway, especially in the trigeminal nucleus caudalis. This study focused to extend our previous work to investigate the changes in monoamine neurotransmitter immunoreactivity changes in spinal trigeminal nucleus oralis, pars interpolaris and nucleus tractus solitaries following mild to moderate closed head traumatic brain injury, which are related to tactile allodynia, touch-pressure sensitivity, and visceral pain. Our results exhibited significant alterations in the excitatory monoamine, serotonin, in spinal trigeminal nucleus oralis and pars interpolaris which usually modulate tactile and mechanical sensitivity in addition to the thermal sensitivity. Moreover, we also detected a robust alteration in the expression of serotonin, and inhibitory molecule norepinephrine in the nucleus tractus solitaries, which might indicate the possibility of an alteration in visceral pain, and existence of other morbidities related to solitary nucleus dysfunction in this rodent model of mild to moderate closed head traumatic brain injury. Collectively, widespread changes in monoamine neurotransmitter may be related to orofacial allodynhias and headache after traumatic brain injury.

Using the refined ICF Linking Rules to compare the content of existing instruments and assessments: a systematic review and exemplary analysis of instruments measuring participation

BACKGROUND

Existing instruments measuring participation may vary with respect to various aspects. This study aimed to examine the comparability of existing instruments measuring participation based on the International Classification of Functioning, Disability and Health (ICF) by considering aspects of content, the perspective adopted and the categorization of response options.

METHODS

A systematic literature review was conducted to identify instruments that have been commonly used to measure participation. Concepts of identified instruments were then linked to the ICF following the refined ICF Linking Rules. Aspects of content, perspective adopted and categorization of response options were documented.

RESULTS

Out of 315 instruments identified in the full-text screening, 41 instruments were included. Concepts of six instruments were linked entirely to the ICF component Activities and Participation; of 10 instruments still 80% of their concepts. A descriptive perspective was adopted in most items across instruments (75%), mostly in combination with an intensity rating. An appraisal perspective was found in 18% and questions from a need or dependency perspective were least frequent (7%).

CONCLUSION

Accounting for aspects of content, perspective and categorization of responses in the linking of instruments to the ICF provides detailed information for the comparison of instruments and guidance on narrowing down the choices of suitable instruments from a content point of view. Implications for Rehabilitation For clinicians and researchers who need to identify a specific instrument for a given purpose, the findings of this review can serve as a screening tool for instruments measuring participation in terms of the following: • Their content covered based on the ICF. • The perspective adopted in the instrument (e.g., descriptive, need/dependency or appraisal). • The categorization of their response options (e.g., intensity or frequency).

Diffuse traumatic brain injury induces prolonged immune dysregulation and potentiates hyperalgesia following a peripheral immune challenge

Background

Nociceptive and neuropathic pain occurs as part of the disease process after traumatic brain injury (TBI) in humans. Central and peripheral inflammation, a major secondary injury process initiated by the traumatic brain injury event, has been implicated in the potentiation of peripheral nociceptive pain. We hypothesized that the inflammatory response to diffuse traumatic brain injury potentiates persistent pain through prolonged immune dysregulation.

Results

To test this, adult, male C57BL/6 mice were subjected to midline fluid percussion brain injury or to sham procedure. One cohort of mice was analyzed for inflammation-related cytokine levels in cortical biopsies and serum along an acute time course. In a second cohort, peripheral inflammation was induced seven days after surgery/injury with an intraplantar injection of carrageenan. This was followed by measurement of mechanical hyperalgesia, glial fibrillary acidic protein and Iba1 immunohistochemical analysis of neuroinflammation in the brain, and flow cytometric analysis of T-cell differentiation in mucosal lymph. Traumatic brain injury increased interleukin-6 and chemokine ligand 1 levels in the cortex and serum that peaked within 1–9 h and then resolved. Intraplantar carrageenan produced mechanical hyperalgesia that was potentiated by traumatic brain injury. Further, mucosal T cells from brain-injured mice showed a distinct deficiency in the ability to differentiate into inflammation-suppressing regulatory T cells (Tregs).

Conclusions

We conclude that traumatic brain injury increased the inflammatory pain associated with cutaneous inflammation by contributing to systemic immune dysregulation. Regulatory T cells are immune suppressors and failure of T cells to differentiate into regulatory T cells leads to unregulated cytokine production which may contribute to the potentiation of peripheral pain through the excitation of peripheral sensory neurons. In addition, regulatory T cells are identified as a potential target for therapeutic rebalancing of peripheral immune homeostasis to improve functional outcome and decrease the incidence of peripheral inflammatory pain following traumatic brain injury.

Behavioral and affective disorders after brain injury: French guidelines for prevention and community supports

OBJECTIVE

The purpose of this study was to elaborate practice guidelines for the prevention of behavioral and affective disorders in adult outpatients after traumatic brain injury (TBI); but also to identify the support systems available for family, caregivers of patients with TBI within the community.

METHODS

The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. This involved a systematic and critical review of the literature looking for studies that investigated the impact of programs in community settings directed to behavioral and affective disorders post-TBI. Recommendations were than elaborated by a group of professionals and family representatives.

RESULTS

Only six articles were found comprising 4 studies with a control group. Two studies showed a beneficial effect of personalized behavior management program delivered within natural community settings for persons with brain injury and their caregivers. Two other studies showed the relevance of scheduled telephone interventions to improve depressive symptoms and one study emphasized the usefulness of physical training. One study investigated the relevance of an outreach program; this study showed an improvement of the patients' independence but did not yield any conclusions regarding anxiety and depression.

DISCUSSION AND RECOMMENDATIONS

In addition to the application of care pathways already established by the SOFMER, prevention of behavioral and affective disorders for brain-injured outpatients should involve pain management, as well as development of therapeutic partnerships. It is recommended to inform patients, their family and caregivers regarding the local organization and facilities involved in the management of traumatic brain injury. The relevance of therapeutic education for implementing coping strategies, educating caregivers on behavioral disorder management, follow-up telephone interventions, and holistic therapy seems established. The level of evidence is low and preliminary studies should be confirmed with larger controlled trials.

Insomnia symptoms and behavioural health symptoms in veterans 1 year after traumatic brain injury

OBJECTIVE

Insomnia and behavioural health symptoms 1 year after traumatic brain injury (TBI) were examined in a clinical sample representative of veterans who received inpatient treatment for TBI-related issues within the Veterans Health Administration.

METHODS

This was a cross-sectional sub-study (n = 112) of the Polytrauma Rehabilitation Centres' traumatic brain injury model system programme. Prevalence estimates of insomnia, depression, general anxiety, nightmares, headache and substance use, stratified by injury severity, were derived. Univariate logistic regression was used to examine unadjusted effects for each behavioural health problem and insomnia by injury severity.

RESULTS

Participants were primarily male, < 30 years old and high school educated. Twenty-nine per cent met study criteria for insomnia; those with mild TBI were significantly more likely to meet criteria (43%) than those with moderate/severe TBI (22%), χ(2)(1, n = 112) = 5.088, p ≤ 0.05. Univariable logistic regression analyses revealed depressive symptoms and general anxiety were significantly associated with insomnia symptoms after TBI of any severity. Headache and binge drinking were significantly inversely related to insomnia symptoms after moderate/severe TBI, but not MTBI.

CONCLUSIONS

Veterans with history of TBI, of any severity, and current insomnia symptoms may be at increased risk for depression and anxiety 1 year after TBI.

Cognitive Impairment and Community Integration Outcomes in Individuals Living With Multiple Sclerosis

OBJECTIVES

To determine the association between unique domains of cognitive impairment and community integration in individuals with multiple sclerosis (MS), and to determine the contributions of cognitive impairment to community integration beyond the influence of demographic and clinical variables.

DESIGN

Cross-sectional analysis of objective neuropsychological assessment and self-report data. Data were collected during baseline assessment of a randomized, multisite controlled trial of ginkgo biloba for cognitive impairment in MS. Hierarchical regression analyses examined the association between subjective and objective measures of cognitive impairment and 3 domains of community integration, adjusting for relevant covariates.

SETTING

Two Veterans Affairs medical center MS clinics.

PARTICIPANTS

Adults (N=121; ages 24-65y) with a confirmed MS diagnosis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Primary outcomes were scores on the Home Integration (CIQ-H), Social Integration (CIQ-S), and Productivity (CIQ-P) domains of the Community Integration Questionnaire (CIQ).

RESULTS

Cognitive impairment was associated with lower scores on the CIQ-H and CIQ-S, but not the CIQ-P. Greater levels of subjective cognitive impairment were associated with lower scores on the CIQ-H and CIQ-S. Greater levels of objective cognitive impairment, specifically slower processing speed and poorer inhibitory control, were related to lower CIQ-S scores. Subjective and objective measures of cognitive impairment were significantly and independently associated with CIQ-S.

CONCLUSIONS

Objective cognitive impairment may interfere with participation in social activities. Subjective cognitive impairment is also important to assess, because individuals who perceive themselves to be cognitively impaired may be less likely to participate in both home and social activities. Clinical interventions to enhance community integration in individuals with MS may benefit from addressing objective and subjective cognitive impairment by integrating cognitive rehabilitation approaches with self-efficacy-enhancing strategies.

Discriminating military and civilian traumatic brain injuries

Traumatic brain injury (TBI) occurs at higher rates among service members than civilians. Explosions from improvised explosive devices and mines are the leading cause of TBI in the military. As such, TBI is frequently accompanied by other injuries, which makes its diagnosis and treatment difficult. In addition to postconcussion symptoms, those who sustain a TBI commonly report chronic pain and posttraumatic stress symptoms. This combination of symptoms is so typical they have been referred to as the "polytrauma clinical triad" among injured service members. We explore whether these symptoms discriminate civilian occurrences of TBI from those of service members, as well as the possibility that repeated blast exposure contributes to the development of chronic traumatic encephalopathy (CTE). This article is part of a Special Issue entitled 'Traumatic Brain Injury'.

Too hard to control: compromised pain anticipation and modulation in mild traumatic brain injury

Mild traumatic brain injury (MTBI) is a vulnerability factor for the development of pain-related conditions above and beyond those related to comorbid traumatic and emotional symptoms. We acquired functional magnetic resonance imaging (fMRI) on a validated pain anticipation task and tested the hypotheses that individuals with a reported history of MTBI, compared with healthy comparison subjects, would show increased brain response to pain anticipation and ineffective pain modulation after controlling for psychiatric symptoms. Eighteen male subjects with a reported history of blast-related MTBI related to combat, and eighteen healthy male subjects with no reported history of MTBI (healthy controls) underwent fMRI during an event-related experimental pain paradigm with cued high or low intensity painful heat stimuli. No subjects in either group met diagnostic criteria for current mood or anxiety disorder. We found that relative to healthy comparison subjects, after controlling for traumatic and depressive symptoms, participants with a reported history of MTBI showed significantly stronger activations within midbrain periaqueductual grey (PAG), right dorsolateral prefrontal cortex and cuneus during pain anticipation. Furthermore, we found that brain injury was a significant moderator of the relationship between anticipatory PAG activation and reported subjective pain. Our results suggest that a potentially disrupted neurocognitive anticipatory network may result from damage to the endogenous pain modulatory system and underlie difficulties with regulatory pain processing following MTBI. In other words, our findings are consistent with a notion that brain injury makes it more difficult to control acute pain. Understanding these mechanisms of dysfunctional acute pain processing following MTBI may help shed light on the underlying causes of increased vulnerability for the development of pain-related conditions in this population.

Persistent pain in adolescents following traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of pediatric disability. Although persistent pain has been recognized as a significant postinjury complication, there is a paucity of data concerning the postinjury pain experience of youth. This study aimed to examine the prevalence of persistent pain in adolescents after TBI, identify risk factors for pain, and evaluate the impact of pain on adolescent health-related quality of life. Participants included 144 adolescents with mild to severe TBI who were followed over 36 months after injury. At 3-, 12-, 24-, and 36-month assessments, measures of pain intensity, depression, posttraumatic stress disorder, and health-related quality of life were completed by adolescents. Findings demonstrated that 24.3% of adolescents reported persistent pain (defined as usual pain intensity ≥3/10) at all assessment points after TBI. Female sex (odds ratio = 2.73, 95% confidence interval = 1.12-6.63) and higher levels of depressive symptoms at 3 months after injury (odds ratio = 1.26, 95% confidence interval = 1.12-1.43) were predictors of persistent pain at 36 months. Furthermore, mixed linear models indicated that early pain experience at 3 months following TBI was associated with a significantly poorer long-term health-related quality of life.

PERSPECTIVE

This is the first study to examine the prevalence of persistent pain over long-term follow-up in adolescents after TBI and its impact on health-related quality of life. These findings indicate that adolescents with TBI may benefit from timely evaluation and intervention to minimize the development and impact of pain.

Pain and mild traumatic brain injury: the implications of pain severity on emotional and cognitive functioning

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.

Rapid EEG activity during sleep dominates in mild traumatic brain injury patients with acute pain

Chronic pain is a highly prevalent post-concussion symptom occurring in a majority of patients with mild traumatic brain injury (mTBI). About half of patients with mTBI report sleep-wake disturbances. It is known that pain can alter sleep quality in this population, but the interaction between pain and sleep is not fully understood. This study aimed to identify how pain affects subjective sleep (Pittsburgh Sleep Quality Index [PSQI]), sleep architecture, and quantitative electroencephalographic (qEEG) brain activity after mTBI. Twenty-four mTBI patients complaining of sleep-wake disturbances, with and without pain (8 and 16, respectively), were recruited 45 (±22.7) days post-trauma on average. Data were compared with those of 18 healthy controls (no sleep or pain complaints). The PSQI, sleep architecture, and qEEG activity were analyzed. Pain was assessed using questionnaires and a 100-mm visual analogue scale. Patients with mTBI reported three times poorer sleep quality than controls on the PSQI. Sleep architecture significantly differed between patients with mTBI and controls but was within normal range. Global qEEG showed lower delta (deep sleep) and higher beta and gamma power (arousal) at certain EEG derivations in patients with mTBI compared with controls (p<0.04). Patients with mTBI with pain, however, showed greater increase in rapid EEG frequency bands, mostly during REM sleep, and beta bands in non-REM sleep compared with patients with mTBI without pain and controls (p<0.001). Pain in patients with mTBI was associated with more rapid qEEG activity, mostly during REM sleep, suggesting that pain is associated with poor sleep and is a critical factor in managing post-concussion symptoms.

A systematic review of early prognostic factors for persisting pain following acute orthopedic trauma

BACKGROUND

Acute orthopedic trauma contributes substantially to the global burden of disease.

OBJECTIVES

The present systematic review aimed to summarize the current knowledge concerning prognostic factors for the presence of persistent pain, pain severity and pain-related disability following acute orthopedic trauma involving a spectrum of pathologies to working-age adults.

METHODS

The Ovid MEDLINE and EMBASE databases were searched for level II prognostic studies published between January 1996 and October 2010. Studies that were longitudinal and reported results with multivariate analyses appropriate for prognostic studies were included. Studies that addressed two specific injury types that have been the subject of previous reviews, namely, injuries to the spinal column and amputations, were excluded.

RESULTS

The searches yielded 992 studies; 10 studies met the inclusion criteria and were rated for methodological quality. Seventeen factors were considered in more than one cohort. There was strong evidence supporting the association of female sex, older age, high pain intensity, preinjury anxiety or depression, and fewer years of education with persistent pain outcomes. There was moderate evidence supporting the association between postinjury depression or anxiety with persistent pain, and that injury severity was not a risk factor for ongoing pain.

CONCLUSION

Many individuals experience persistent pain following acute trauma. Due to the lack of studies, the use of different constructs to measure the same factor and the methodological limitations associated with many of the studies, the present review was only able to reliably identify a limited set of factors that predicted persistent pain. Recommendations for the conduct of future methodologically rigorous studies of persistent pain are provided.

The Community Approach to Participation: Outcomes Following Acquired Brain Injury Intervention

Objective: To investigate the participation outcomes of individuals with severe acquired brain injury (ABI) who were provided with up to 12 months of intervention based on the Community Approach to Participation (CAP). Method: A case series study design was undertaken with a total of 85 participants from two private practices specialising in community-based, CAP rehabilitation for people with severe ABI. Inclusion criteria were the person had sustained an acquired brain injury, was aged over 18 years and had received up to 12 consecutive months of CAP input from one of the two practices within a three-year period between January 2004 and January 2007. Twenty-six of the 85 participants were an average of 343 days post injury (Early group) and 59 of the participants were an average of 10.2 years post injury (Late group). They were living in a range of community environments and residential facilities. Initial participants were identified for the study in January 2005. Data were gathered using the Functional Independence Measure (FIM™), Community Integration Questionnaire (CIQ), and Role Checklist (RC Part 1) at two time points: prior to intervention (baseline), and after a 12-month period or at discharge (TI). Within the intervention period, all participants received a customised community occupational therapy (OT) rehabilitation program based on the key principles of the CAP. Intervention focused on participation goals of the individual, and development of the associated skills that underpinned valued role performance. Results: Participants each received an average of 51.01 hours of CAP OT during the 12-month period of intervention. Considerable improvement was seen in functional independence, community integration, and role participation after intervention in both the Early and Late groups. A statistically significant increase in FIM™ and CIQ total scores was found for all participants from Baseline to T1. The number of roles in which participants engaged increased on average by almost one role per participant following intervention, from a mean of 3.06 to 3.99. Increased participation in volunteer, home maintainer, participant in organisations and hobbyist roles were most common. Conclusion: Increased functional independence, community integration, and participation in both the Early and Late groups over a 12 month period demonstrates the potential for improved participation outcomes for people with complex needs following ABI, even many years post injury.

Comparison of subjective and objective assessments of outcome after traumatic brain injury using the International Classification of Functioning, Disability and Health (ICF)

PURPOSE

The aim is to examine two aspects of outcome after traumatic brain injury (TBI). Functional outcome was assessed by the Glasgow Outcome Scale - Extended (GOSE) and by clinician ratings, while health-related quality of life (HRQoL) was assessed by the Quality of Life after Brain Injury (QOLIBRI).

METHOD

The GOSE and the QOLIBRI were linked to the International Classification of Functioning, Disability and Health (ICF) to analyse their content. Functional outcome on ICF categories was assessed by rehabilitation clinicians in 55 participants with TBI and was compared to the participants' own judgements of their HRQoL.

RESULTS

The QOLIBRI was linked to 42 and the GOSE to 57 two-level ICF categories covering 78% of the categories on the ICF brief core set for TBI. The closest agreement in the views of the professionals and the participants was found on the Physical Problems and Cognition scales of the QOLIBRI.

CONCLUSIONS

The problems encountered after TBI are well covered by the QOLIBRI and the GOSE. They capture important domains that are not traditionally sufficiently documented, especially in the domains of interpersonal relationships, social and leisure activities, self and the environment. The findings indicate that they are useful and complementary outcome measures for TBI. In rehabilitation, they can serve as tools in assessment, setting meaningful goals and creating therapeutic alliance.

Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury

OBJECTIVE

To review the literature addressing the assessment and management of pain in patients with polytraumatic injuries including traumatic brain injury (TBI) and blast-related headache, and to identify patient, clinician and systems factors associated with pain-related outcomes.

DESIGN

Systematic review.

METHODS

We conducted searches in MEDLINE of literature published from 1950 through July 2008. Due to a limited number of studies using controls or comparators, we included observational and rigorous qualitative studies. We systematically rated the quality of systematic reviews, cohort, and case-control design studies.

RESULTS

One systematic review, 93 observational studies, and one qualitative research study met inclusion criteria. The literature search yielded no published studies that assessed measures of pain intensity or pain-related functional interference among patients with cognitive deficits due to TBI, that compared patients with blast-related headache with patients with other types of headache, or that assessed treatments for blast-related headache pain. Studies on the association between TBI severity and pain reported mixed findings. There was limited evidence that the following factors are associated with pain among TBI patients: severity, location, and multiplicity of injuries; insomnia; fatigue; depression; and post-traumatic stress disorder.

CONCLUSIONS

Very little evidence is currently available to guide pain assessment and treatment approaches in patients with polytrauma. Further research employing systematic observational as well as controlled intervention designs is clearly indicated.