Chronic Pain and mTBI

Check for Mild Traumatic Brain Injury (mTBI or concussion) when Treating Chronic Pain

About 1.7 million people suffer a traumatic brain injury (TBI) in the U.S. each year, according to the Centers for Disease Control and Prevention (CDC). About 75% of these are classified as mild, or mTBIs, also known as concussion. TBIs increase the risk of chronic pain, as well as of comorbid conditions, such as depression, anxiety, and post-traumatic stress disorder (PTSD), which can amplify chronic pain. 

football, a common cause of mTBI or concussionWhat to do when treating pain and mTBI (concussion) is suspected

  • Ask patients with pain about possible head injuries.

  • Ask patients with pain about depression and anxiety.

  • Track patients with head injuries closely in the days immediately after injury.

  • Know that pain and other distressing symptoms from most mTBIs will resolve in 2-4 weeks.  However, in some cases mTBIs and associated injuries can develop into chronic pain.

  • Ensure that only safe combinations of medications for co-occurring conditions are used. In particular, use of prescription opioids for chronic pain and benzodiazepines for anxiety related to TBI can lead to respiratory depression and death.

Categorizing TBIs

Traumatic brain injury or TBI is an injury to the brain caused by an outside force, such as a direct blow to the head, or indirect forces that cause a violent jarring of the brain, such as a shock wave from an explosion or rapid acceleration and de-acceleration that occurs during a car accident. TBIs can be either open, with scalp and/or skull injury, or closed, with no external sign of injury. TBIs are categorized as mild, moderate, or severe, depending on acute and chronic symptoms. The majority of TBIs are classified as mild, or mTBIs, also known as concussions.

women in military helmet with mTBI or concussionSymptoms of mTBI can include:

  • Headache, shoulder pain and neck pain
  • Confusion
  • Difficulty waking
  • Loss of consciousness
  • Nausea and vomiting

Common causes of TBI:

  • Explosive blasts as a result of war or conflict: From 2000 through 2011, 235,046 U.S. service members were diagnosed with a TBI. About 75% of these injuries were categorized as mTBIs, or concussions. Rates of TBI among active duty service members more than doubled from 2000 to 2011, from 720.3 to 1,811.4 per 100,000; in 2011 rates were highest in the Army (2717.85 per 100,000), three times the rate for the Navy (860.56 per 100,000). Statistics include TBIs from vehicle accidents and falls, as well as warfare.
  • Sports injuries: Among U.S. high-school athletes, rates of mTBI or concussion are highest among athletes playing football (11.2 mTBI per 10,000 “athletic exposures”), lacrosse (5.2 for women and 6.9 for men), and soccer (6.7 for women and 4.2 for men), according to 2012 data released by the Institute of Medicine and the National Research Council. 
  • Falls: Falls cause 40% of TBIs in the U.S., with rates highest among children aged 0-14 years and adults aged 65 years and older.
  • Motor vehicle collisions: Car and other vehicle collisions are the leading cause of U.S. TBI-caused deaths in children and young adults aged 5-24 years.

TBI: Depression, anxiety, PTSD and pain

  • About half of all people with TBI are affected by depression within the first year after injury and two-thirds are affected within seven years. These rates are five to six times higher than rates of depression in the general population (about 10%). About half of the people with TBI and depression also have anxiety.
  • Symptoms of TBI and PTSD often co-occur and amplify overlapping symptoms. TBI increases the risk of PTSD. 
  • Co-morbid depression, anxiety, and PTSD all increase the risk of chronic pain.
  • Treating chronic pain with long-term opioids may slow recovery in people with PTSD and TBI.