Medical Conditions Related to Brain Injury
Pain Management in Brain Injury
Last Updated:
Pain management in brain injury can be challenging because persons with traumatic brain injury (TBI) often have injuries to multiple parts of their bodies in addition to the brain itself. These injuries may be difficult for doctors to identify in the acute setting. In ICU, physicians are busy addressing the patient’s life-threatening issues and unfortunately the person, if experiencing altered mental status such as coma, cannot complain. It’s estimated that 17% of bony injuries and fractures are missed early on.
The first step in identifying musculo-skeletal problems is a rigorous physical exam that tests the range of motion at each joint. However, if the exam doesn’t take place soon after the trauma, the tone in the muscles may heighten causing the muscle to become spastic. Spasticity, in turn, can hide weakness in the muscles. Some patients give clues that something is wrong by manifesting aggression, motor restlessness, or paresis (muscle weakness). But as a rule, “if it hurts to move it, they won’t move it.” This immobility may even appear to be paralysis and not until patients can communicate or test the limb themselves can the problem be assessed.
The detection process is further complicated if the TBI has compromised communication between the injured part of the body and the brain. If the pain signal is thwarted along the way and a person who should feel pain, does not, injured areas may not be treated. This signal can improve with time. In general, greater cognitive awareness brings a greater awareness of pain.
Besides identifying other physical problems, pain management in brain injury is difficult because the most common approaches used to reduce pain are counterproductive to what is helpful in brain injury recovery. Western medicine tends to treat the symptom, not the cause. The philosophy is “get rid of the pain at any cost.” Patients may be given high doses of narcotics by mouth, IV, or via pumps to alleviate discomfort, but these do nothing to treat the pain; they simply alter a person’s state of mind so he or she is no longer aware of it.
This approach can be problematic in brain injury. Early on, narcotics, which suppress cognition (the ability to think) and respiration, work against the higher priority of awakening the person’s mental and physical systems. Later, narcotics are a problem because of their potential for substance abuse and their negative side effect on the ability think clearly. Whenever possible, it is advisable to treat pain without narcotics. This is easier to do once the source of pain has been identified.
Common causes for pain are:
- fracture
- abscess
- heterotopic ossification/ bony overgrowth (HO)
- kidney stones
- bladder infections
- skin sores
- spasticity
- neck/cervical/spine injury
- constipation
- headaches
The following may be effective in controlling pain, depending on the pain’s source.
Antibiotics are the treatment of choice for infections. A high white blood cell count (WBC) is a strong indicator of infection. A simple test may reveal infection, but its source can be harder to find and therefore to treat.
However, once under control, the symptoms associated with the infection (which cause the pain) usually disappear.
Anti-inflammatory agents such as Motrin, Naprosyn, and Celebrex are appropriate for musculo-skeletal pain, though doctors must stay alert for possible gastric problems. Patients with brain injury and spinal cord injury tend to have high acid content in the stomach and are susceptible to stomach ulcers which can be exacerbated by anti-inflammatory agents. Benedryl, Ultram, Tylenol, and TENS (transcutaneous electrical nerve stimulation) may be better choices if gastric issues are involved.
Antidepressants (Paxil, Zoloft) and even other medications like Tegretol and Neurontin which are anticonvulsants, can be effective in controlling headeache and nerve pain. These are not sedating except in high doses, and don’t depress the respiratory cycle.
Alternative medicine such as acupuncture is worth exploring when the traditional medications the patient can take fail to reduce pain to a tolerable level.
The adage for brain injury is: use no medication that will alter the central nervous system to the degree that it would lessen cognition. Brain injury is for life. In managing pain, the physician, family, and person with brain injury must consider the long-term ramifications of any medications prescribed.
Dr. Donald Leslie is Associate Medical Director of Shepherd Center and an elected member of the Center’s Board of Directors. He is Medical Director of brain injury services at Shepherd, which includes inpatient and post-acute brain injury rehabilitation programs and recently became head of their new geriatric brain injury unit. He is Co-Medical Director of the Georgia Model Brain Injury System. Dr. Leslie has spoken nationally and internationally on spasticity management, and has been involved in intrathecal baclofen research and therapy for the past ten years. Most recently, Dr. Leslie received certification in acupuncture at UCLA in Santa Monica, California.