Analgesic Ladder in TBI
Pain Management
Jim Plunkett, M.D.
VA Medical Center/UC Dept of
PM&R
2013 NKY TBI Conference
March 22, 2013
Chronic Pain
 IASP



definition
“an unpleasant sensory or emotional
response to a stimulus associated with actual
or potential tissue damage”
Pain “lasting longer than the anticipated
course of recovery” – often 3-6 months
Neurologic, physiologic, and emotional
components ( suffering)
Nociceptive Pain
 Noxious
stimuli activating peripheral
receptors producing typical acute pain
along a-delta and C fibers



Pin-prick or stab wound or stubbed toe
Burn injury
Fractures
Neuropathic Pain
 Pain
associated with injury or disease of
peripheral nerves

DM peripheral neuropathy
Shingles ( PHN)
Radiculopathy

Burning, shooting, lancinating pain

Allodynia, hyperpathia, central sensitization


Beginning to End: The Chronic Pain Cycle
Pathophysiology of Maintenance:
-Radiculopathy
-Neuroma traction
-Myofascial sensitization
-Brain, SC pathology (atrophy, reorganization)
Psychopathology
of maintenance:
Acute injury
and pain
-Encoded anxiety
dysregulation
- PTSD
-Emotional
allodynia
-Mood disorder Neurogenic
Inflammation:
- Glial activation
- Pro-inflammatory
cytokines
- blood-nerve barrier
dysruption
Pathology:
-Muscle atrophy,
weakness;
-Bone loss;
-Immunocomprimise
-Depression / Suicide
Central
Sensitization
-Neuroplastic
changes
Peripheral
Sensitization:
New Na+ channels
cause lower
threshold
Disability
Less active
Kinesophobia
Decreased
motivation
Increased
isolation
Role loss
Gallagher RM, in Ebert & Kerns, 2010)
Prevalence of Chronic Pain, PTSD and TBI in a sample of
340 OEF/OIF veterans
Chronic Pain
N=277
PTSD
N=232
16.5%
81.5%
10.3%
2.9%
68.2%
42.1%
12.6%
TBI
N=227
6.8%
5.3%
66.8%
Lew, Otis, Tun et al., (in Press). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive
Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD
WHO Analgesic Ladder
 Step
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 Step
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 Step

1986
1: Non-opioids (tylenol +/- NSAID)
+/- adjuvants
2: “Weak opioids”
+ non-opioids +/- adjuvants
3: “ Strong opioids”
+ non-opioids +/- adjuvants
Expanded Analgesic Ladder
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Activity modification
Thermal modalities
Electrical topical modalities
Topical medical analgesics
Gait and mobility aides
Bracing
Stretching/ROM/massage
Strengthening
Aerobic reconditioning
Basic self-care health habits
Ladder ( con’t)
Non-opioids


Acetaminophen
Aspirin

NSAIDS

Adjuvants
 Muscle
relaxants
 Anti-epileptic drugs ( AEDs)
 Anti-depressants
 Corticosteroids
Narcotics
 Pseudo-narcotics
( tramadol)
 Weak potency vs. Strong potency
 Short-acting vs. Long- acting
 Oral vs. topical vs. transmucosal vs. IV
 Combination
Invasive procedures
 Basic

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Myofascial trigger point injections
Intra-articular injections
Botox – headache and spasticity
Acupuncture
Nerve blocks
Invasive procedures
 Advanced:
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( Fluoro-guided)
Cervical, thoracic, and lumbosacral ESI
Facet injections
Medial branch blocks
Sacro-iliac joint injections
RF nerve ablation
IDET
Stellate ganglion and LS sympathetic blocks
Celiac plexus block, Bier block
Quaternary Interventions
 Spinal
Cord ( or Dorsal column) stimulator
 Intrathecal Pain pump
 Rhizotomy or myelotomy
 Deep Brain stimulation
 Thalatomy
Cognitive/Behavioral therapies
 Progressive
relaxation
 Guided imagery
 Individual and Group therapy
 Cognitive/behavioral therapy
 Biofeedback
Pain Categories
 “Orthopedic”


OA/DJD
Muscles, tendons, ligaments
 “Neuropathic”



Myelopathy, radiculopathy
Peripheral neuropathy
Complex/Central Pain
Categories
 Above
+ Chronicity help guide treatment
 Other factors – Secondary Gain

Workmen’s Comp, Tort claim, SSDI
 Medical
co-morbidities
 Traumatic Brain Injury
 Age
Headache
Episodic Headache
Chronic Daily Headache
•Characterize type
•Abortive therapy
•> 15 HA days per month
•Analgesic rebound
•Prophylaxis is key
•Maximum 6 doses/week
Avoid narcotics
& Benzos
Prophylaxis
Abortive
NSAIDs
•GI side effects
Ibuprofen
Naproxen Sodium
Aspirin
Triptans
•Contraindicated in
patients with CAD
Onset of action ~ 4 wks
Combination
Medications
Alternatives
Promethazine
Metoclopramide
•Cognitive side effects Prochloroperazine
•Risk of W/D
Tizanidine
Non-medication
Fioricet
Trigger point injection
Fiorinal
Occipital nerve block
Midrin
Physical therapy
Anti-depressants AEDS
•May improve mood
•Improves sleep
Nortriptylline
Amitryptilline
Paroxetine
Fluoxetine
•Neuropathic pain
gabapentin
•Mood lability
valproic acid
topirimate
Beta-blockers
•Non-selective may
have benefit on
autonomic effects of
PTSD
Propranolol
Drug Interactions
Headache
Drug
PTSD Drug
Tricyclic
SSRIs
Antidepressants
Triptans
Propranolol
Interaction
Inc TCA levels
2) Serotonin
syndrome
1)
SSRIs
Serotonin
Syndrome*
Prazosin
Additive lowering
of BP, orthostasis
Tricyclic
Additive increase
Benzodiazepine in sedation
Antidepressants
Back to Ladder details
 Activity
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modifications
“RICE” + Lifting and positional limitations
Work hours and work pacing
Rotation of repetitive tasks
Ergonomic adjustments
Biomechanical optimization
Graduated return to work
Topical modalities

Ice
 Heat
 Topical analgesics

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
Capsaicin
Lidoderm
Camphor, menthol and salicylates ( Ben-gay)
Ultrasound or Iontophoresis ( steroids/NSAIDs)
 TENS unit
 E-stim, Biovest, Alpha stim
 Cold laser
Gait and mobility aides
 Cane
 Walker
incl. Rolling walker w/ fold-down
seat
 Wheelchair ( manual vs. electric)
 Scooter
Orthotics
 Lumbar
support
 Wrist splint +/- thumb spica
 Elbow pads, arm sling
 Soft cervical collar
 Knee brace – hinged/unhinged
 Ankle brace or AFO
 PTB AFO
 Shoe orthotic inserts, sole modifications
PT + HEP
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Stretching/ROM/soft tissue mobilization
Strengthening – Isometric -> Isotonic
Work or activity - specific training
Plyometrics
Basic or modified aerobic reconditioning

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Walking/treadmill - graduated
Bike riding – upright/recumbent
Aquatic – based
Cardiopulmonary parameters
Massage Therapy
 Craniosacral
techniques for TBI
Chiropractic
 Manipulation
 Modalities
Basic Selfcare – Health habits
– diet
 Smoking
 Alcohol
 Drug abuse
 Sleep hygiene
 Stress management
 Obesity
Basic analgesics
 Acetaminophen


Hepatic caveats
ASA

GI monitoring
( NTE 4000 mg/day)
NSAIDs

Salicylates


Propionic acids


Piroxicam
Cox-2 Inhibitors


Indomethacin, diclofenac, sulindac, toradol
Oxicams

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Ibuprofen, Naproxen, ketoprofen, Oxaprasin
Acetic acids

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Non-acetylated ( Salsalate, Disalcid, Trilisate)
Celebrex
Xyflamend – herbal - OTC
Muscle relaxants
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Cyclobenzaprine ( TCA)
Parafon forte, methocarbamol, carisoprodol
Dantrium
Baclofen
Tizandine
Diazepam
Caveat re sedation and liver function
 Soma – ( and valium) dependency
Neuropathic agents
 Antidepressants

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TCA – ami/nortriptyline, trazodone,
desipramine
SSRI’s:
SNRI’s: venlafaxine, duloxetine
Neuropathic agents
 Anti-epileptic
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drugs:
Carbamazepine, oxcarbazepine
Topiramate, Keppra
Gabapentin ( Neurontin)
Pregabalin ( Lyrica)
Watch for CNS SE, drug interactions esp
tegretol
LFT and WBC monitoring
Oral steroids
 Medrol

dospak ( Methylprednisolone)
Prednisone taper ( 40 mg -> 0 over 12 d)
 GI,
DM, cataract, osteoporosis
 But
also watch out for Bipolar d/o
Narcotics
 Pseudo-narcotic

Tramadol – mu agonist activity

Mild analgesia


Watch for serotonin syndrome w/ SSRI’s
Habit-forming
Narcotics
 Mild
 Propoxyphene

( Darvocet/Darvon)
No efficacy > tylenol – removed from market
 Codeine


Poor GI tolerance
2-10 % transformation to morphine
Narcotics
 Short-acting

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Oxycodone – schedule II
Hydrocodone – schedule III-> II
Meperidine ( Demerol)
Hydromorphone ( Dilaudid)
• Avoid for chronic pain – rapid accommodation

Morphine IR
Narcotics
 Long-acting
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OxyContin
Morphine SR, MS Contin
Avinza, Opana
Methadone
Fentanyl patch or lollipop
Tapentadol (Nucynta)
Narcotic SE
 Common
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N/V
Constipation – proactive bowel regimen
Sedation *** Key to avoid in TBI**
Itching
Physiologic/psychological dependence
Sweating
Anorexia
Myoclonus
Narcotic SE
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Myoclonus
Dizziness/orthostasis
Accommodation
Respiratory suppression
Cardiac dysrhythmia – methadone
Methadone also difficult to achieve
equianalgesic dosing + occ idiosyncratic buildup
w/ long ½ life > analgesic effect
Narcotic Issues
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Avoid as unimodal pharmacologic approach –
opioid sparing concept
Possible opioid hyperalgesia
May need to rotate type of narcotic if
accommodated
Addiction vs Pseudo-addiction ( UDS)
Dependency – physiologic/psychologic
Taper ( 50 %/week) vs. Detox
Buprenex vs. methadone maintenance
PTSD
Pain
Medication effects
Pain
Mild
TBI
Residua
Re-experiencing
Avoidance
Social withdrawal
Memory gaps
Apathy
Difficulty with decisions
Mental slowness
Concentration
Headaches
Dizzy
Appetite changes
Fatigue
Sadness
Suicidality
Depression
Altered Arousal
Sensitive to noise
Concentration
Insomnia
Irritability
Substance
Use (Poly)
Conservative
management of pain
after TBI
Rachel Heberling, MD
Cincinnati VA Medical Center
University of Cincinnati
Why Conservative Pain
Management in TBI?
 Increased
sensitivity to medications
 Increased difficulty managing medications,
especially prn’s
 Increased self-efficacy via selfmanagement
 Potentially decreased number of office
visits
 Cost-effective
Heat
 Superficial
heat: heating pad, hot shower,
hot bath
 Deep heat: ultrasound
 Effective
for pain relief, increased muscle
flexibility
 Not much evidence, but obviously effective
briefly
Cold
 Superficial:
Ice packs
 Deep: cold laser
 Cold
effective for pain relief and reducing
inflammation, but contracts muscles
 Unclear mechanism and efficacy of cold
laser
STRETCHING!
 Muscle
has viscoelastic properties
 Slow, deep stretch paired with deep
breathing necessary
 Muscle properties change for ~10 hrs after
deep stretch
 Evidence
not compelling, but pain-relief
effect of stretching is very obvious
clinically
Stretching!
Other types of Exercise
exercise – has huge role in
decreasing muscle tension and
consequent pain.
 Strength training – some role in
decreasing pain (e.g. core strengthening),
but generally minimized until pain
beginning to improve.
 Aerobic
Meditation
 Increasing
base of evidence for the pain
relief effects of meditation
 Decreases stress
 Improved emotional acceptance of pain
Yoga
 EXCELLENT
choice for exercise
maintenance
 Has role in decreasing active pain issues
as well.
 Must start in beginner class!
Advanced Yoga Class
Tai Chi
 Becoming
more popular topic of research
 Have found that Tai Chi practice
decreases falls in the elderly
 Somewhat similar to yoga, but more
focused on gentle fluid movement, as
opposed to deep prolonged stretch
Physical Therapy
 Many
treatment modalities available
 Stretching
 Strengthening
 Ultrasound
 TENS
 Traction
Bracing & Assistive Devices
 Lumbar
support
 Knee braces
 Cane
 Walker
Acupuncture
Acupuncture
WHO, NIH Consensus Study

Classified disease
 Proven
processes according to  Needs further research
evidence for
 Worth trying
acupuncture efficacy
 2003
Diseases, symptoms or conditions for which acupuncture
has been PROVEN-through controlled trials-to be an
effective treatment:

Adverse reactions to radiotherapy
and/or chemotherapy
Allergic rhinitis (including hay
fever)
Biliary colic
Depression (including
depressive neurosis and
depression following stroke)
Dysentery, acute bacillary
Dysmenorrhoea, primary
Epigastralgia, acute (in peptic
ulcer, acute and chronic gastritis,
and gastrospasm)
Facial pain (including
craniomandibular disorders)
Headache
Hypertension, essential
Hypotension, primary

Induction of labour
Knee pain
Leukopenia
Low back pain
Malposition of fetus, correction of
Morning sickness
Nausea and vomiting
Neck pain
Pain in dentistry (including dental
pain and temporomandibular
dysfunction)
Periarthritis of shoulder
Postoperative pain
Renal colic
Rheumatoid arthritis
Sciatica
Sprain
Stroke
Tennis elbow
WHO Acupuncture and The NIH Consensus Study
Diseases, symptoms or conditions for which the
therapeutic effect of acupuncture has been shown but
for which FURTHER PROOF IS NEEDED:

Abdominal pain (in acute
gastroenteritis or due to
gastrointestinal spasm)
Acne vulgaris
Alcohol dependence and
detoxification
Bell’s palsy
Bronchial asthma
Cancer pain
Cardiac neurosis
Cholecystitis, chronic, with acute
exacerbation
Cholelithiasis
Competition stress syndrome
Craniocerebral injury, closed
Diabetes mellitus, non-insulindependent
Earache
Epidemic haemorrhagic fever
Epistaxis, simple (without
generalized or local disease)

Eye pain due to subconjunctival
injection
Female infertility
Facial spasm
Female urethral syndrome
Fibromyalgia and fasciitis
Gastrokinetic disturbance
Gouty arthritis
Hepatitis B virus carrier status
Herpes zoster (human (alpha)
herpesvirus 3)
Hyperlipaemia
Hypo-ovarianism
Insomnia
Labour pain
Lactation, deficiency
Male sexual dysfunction, nonorganic Ménière disease
Neuralgia, post-herpetic
WHO Acupuncture and The NIH Consensus Study
Diseases, symptoms or conditions for which the
therapeutic effect of acupuncture has been shown but
for which FURTHER PROOF IS NEEDED:

Neurodermatitis
Obesity
Opium, cocaine and heroin
dependence
Osteoarthritis
Pain due to endoscopic
examination
Pain in thromboangiitis obliterans
Polycystic ovary syndrome (SteinLeventhal syndrome)
Postextubation in children
Postoperative convalescence
Premenstrual syndrome
Prostatitis, chronic
Pruritus
Radicular and pseudoradicular
pain syndrome
Raynaud syndrome, primary

Recurrent lower urinary-tract
infection
Reflex sympathetic dystrophy
Retention of urine, traumatic
Schizophrenia
Sialism, drug-induced
Sjögren syndrome
Sore throat (including tonsillitis)
Spine pain, acute
Stiff neck
Temporomandibular joint
dysfunction
Tietze syndrome
Tobacco dependence
Tourette syndrome
Ulcerative colitis, chronic
Urolithiasis
Vascular dementia
Whooping cough (pertussis)
WHO Acupuncture and The NIH Consensus Study
Diseases, symptoms or conditions for which there are
only individual controlled trials reporting some
therapeutic effects, but for which acupuncture is WORTH
TRYING because treatment by conventional and other
therapies is difficult:

Chloasma

Neuropathic bladder in
spinal cord injury

Choroidopathy, central
serous

Pulmonary heart disease,
chronic

Colour blindness

Small airway obstruction

Deafness

Irritable colon syndrome

Hypophrenia
GERAC – Design






Journal of Alternative and Complementary Medicine. Volume 12,
Number 8, 2006. pp 733-42
German Acupuncture Trials for Low Back Pain
1162 patients in Germany at 340 centers
Chronic non-specific low back pain >6 months
Compared verde vs sham vs conventional
guideline-based treatment
Semi-standardized verde acupuncture
treatment protocol
GERAC – Design
 10
sessions over 10 weeks regardless of
group
 5 additional sessions for partial
responders (>10%, <50% improvement)
 Limited communication with acupuncturist
to avoid unblinding
 Allowed NSAID for rescue, max twice
weekly.
GERAC - Results
Table 4. Primary Outcome: Pairwise Comparison
of Treatment Response 6 Months After Randomization
Treatment Response
Group 1 vs group 3
47.6 (42.4 to 52.6) vs
27.4 (23.0 to 32.1)
Group 2 vs group 3
44.2 (39.2 to 49.3) vs
27.4 (23.0 to 32.1)
Group 1 vs group 2
47.6 (42.4 to 52.6) vs
44.2 (39.2 to 49.3)
Intergroup Difference
P Value
20.2 (13.4 to 26.7)
0.001
16.8 (10.1 to 23.4)
0.001
3.4 (−3.7 to 10.3)
0.39
GERAC - Results



Treatment Response After 6 Months
Conventional
Sham Acupuncture
Verum Acupuncture




CPGS
Success
132 (34.1)
HFAQ
Success
195 (50.4)
Combined CPGS and HFAQ
Success
223 (57.6)



Combined GCPS, HFAQ
Nonresponders
164 (42.4)
Responders
223 (57.6)



Overall treatment response including proscribed rescue medication
Nonresponders
281 (72.6)
216 (55.8)
203 (52.4)
Responders
106 (27.4)
171 (44.2)
184 (47.6)

197 (50.9)
229 (59.2)
251 (64.9)
281 (72.6)
277 (71.6)
304 (78.5)
125 (32.3)
262 (67.7)
112 (28.9)
275 (71.1)