Understanding the Intersection of Mild Traumatic Brain Injury (mTBI or concussion) and Chronic Pain
An interview with Jesse Fann, MD, MPH
Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Adjunct Professor, UW SOM Department of Rehabilitation Medicine; Affiliate Investigator, Fred Hutchinson Cancer Research Center; and Director of Psychiatry and Psychology Services, Seattle Cancer Care Alliance
Understanding traumatic brain injury (TBI) can be critical to effective treatment of chronic pain. Each year an estimated 1.7 million people in the U.S. suffer a TBI. Most of these are mild TBIs (mTBIs), a term that’s synonymous with concussion. Incidence and severity of chronic pain can increase with TBI, but this connection is not always well understood.
To learn more about TBI and how it can affect pain, COPE interviewed Dr. Jesse Fann, a psychiatrist who treats civilians and military personnel and researches effective treatments for TBI. Dr. Fann is a co-director of the LIFT (Life Improvement Following Traumatic Brain Injury) program, which promotes understanding of and effective treatments for depression after TBI; and collaborator on the CONTACT (CONcussion Treatment After Combat Trauma) study, which found that telemedicine is often effective in treating emotional distress, including depression, PTSD and sleep, and other quality of life issues that may occur after a TBI. In July 2015, Dr. Fann was named by Newsweek as one of the Top Cancer Doctors 2015.
Q: What is the definition of a Traumatic Brain Injury (TBI)?
A: A TBI is an injury that disrupts the normal function of the brain that is caused by a bump, blow, or jolt to the head or a penetrating head injury, such as a gunshot wound. Most TBIs are closed-head injuries in which the soft tissue of the brain is shaken around and there’s stretching and tearing of neurons. TBIs are categorized as mild, moderate, or severe. In the US, about 75% of TBIs are categorized as mild (mTBIs). About 90% of people with mTBIs don’t lose consciousness as a result of their injury. TBIs can occur without direct impact to the head, for example, during whiplash injuries when rapid acceleration and deceleration forces can injure the brain.
Q: What’s the risk of pain after TBI?
A: Most people with mTBI have a relatively quick and natural recovery from any head, shoulder, and neck pain over the course of 2-6 weeks. During that time, it’s important to provide a level of reassurance and monitoring, and to understand that people with mTBI can have a constellation of other symptoms that can be quite distressing, like depression, anxiety, irritability, fatigue, sleep problems, and/or dizziness. Initial rest, followed by gradual increase in movement and exercise, are generally recommended.
However, mTBIs can increase the risk of chronic pain. Prevalence of chronic pain increases among persons with more severe TBIs, not only because of their brain injuries, but because they often also have orthopedic or abdominal injuries that can be independent causes of pain.
Q: What signs or symptoms might indicate that a patient with pain may be suffering from a TBI?
A: The most common types of pain after TBI are headache, neck, back, and shoulder pain. If a patient has those types of pain, it would be reasonable to wonder about a recent or possible history of TBI and to ask the patient if they have suffered an injury. Other things to consider are if the patient appears to have new onset cognitive problems, or other symptoms that are common after a TBI, such as dizziness, balance problems, light sensitivity, blurry vision, or fatigue.
Q: What tools do you recommend for diagnosing TBI?
A: There is no standard measure universally used to retrospectively test for TBI. The Glasgow Coma Scale, which assesses eye opening, motor and verbal responses; duration of loss of consciousness; and post-traumatic amnesia (PTA) are standard assessments used to categorize TBIs in the acute setting, but many patients with mTBIs aren’t evaluated during that time period. In addition, loss of consciousness is not a necessary criterion for mTBI and most mTBIs do not show abnormalities on CT scans or MRIs.
The most important question is to ask patients if they’ve had any injury in which their head has been struck or their head struck something else, and if this was followed by a period of loss of consciousness or feeling dazed or confused. Ask about other injuries in which it may not have been obvious that the head was impacted, including sports activities, falls, and car accidents, which are a common cause of whiplash injuries.
Q: How might diagnosis of TBI affect treatment for pain?
A: In the days immediately after the injury, providers should carefully monitor patients. If their headache gets worse, they should be evaluated urgently, because they might have a subdural hematoma (a collection of blood in the tissues that surround the brain) that’s evolving. Other symptoms to watch for that require urgent attention include: repeated vomiting, inability to stay awake, increased confusion, restlessness or agitation, difficulty walking, weakness or numbness, difficulty with vision, or bowel or bladder leaks.
It’s always important for a provider treating pain to know all the other medications the patient is taking. For example, persons with a more severe TBI might take an anticonvulsant, which may interact with other medications. Also, people with TBI are more vulnerable to certain medication side effects, such as sedation and cognitive impairment.
It’s also critical to consider cognitive and psychological issues. We know that persons with TBI are at an increased risk for comorbid conditions such as depression, anxiety and PTSD that can also amplify the severity of pain and the potential for treatment resistance.
Luckily, some medications, like antidepressants, have the advantage of treating pain as well as other symptoms common after TBI, such as depression, anxiety, or insomnia, therefore minimizing the number of medications that the patient needs to take. Psychotherapies, such as cognitive behavioral therapy, can also be very effective for these conditions.
Q: TBI can result in cognitive impairments in some patients. How can this affect treatment?
A: People with moderate to severe TBIs often have cognitive issues that might affect concentration, memory, and problem-solving. These cognitive issues could impact a patient’s ability to follow medication regimens or to participate in certain types of psychotherapy. We’ve developed a list of accommodations on our LIFT website that can increase the success of treatment for persons with cognitive issues, such as addressing one subject at a time, and providing written summaries of treatment sessions.
Providers should also understand that after a brain injury people oftentimes have a number of psychosocial stressors, such as problems with school or work, or relationship issues. These can be caused by cognitive problems, as well as the emotional aspects of TBI, like depression, anxiety, irritability, and anger issues. It’s also important to assess for alcohol and drug issues. There is a higher rate of alcohol and drug use in people with TBI than in the general population. Alcohol or drug use may have actually contributed to a patient’s TBI, for example; if he or she was driving under the influence.
Q: Why are psychological and behavioral problems underdiagnosed in persons with TBI? How can we ensure that patients get the treatment they need?
A: Patients and providers often focus on pain and other symptoms and medical issues and can unintentionally overlook the psychological and behavioral aspects of TBI. In addition, patients will often focus on physical and cognitive aspects of TBI much more than emotional aspects. Providers need to look for and ask the patient about emotional problems after TBI. It’s also important to talk to family and other caregivers, because they will often notice emotional issues more than the patients will.
In addition, stigma is a huge barrier for people. For example, it’s important to educate patients and families that what we call depression is a medical condition, not too much different from high blood pressure or diabetes. Depression is not a sign of weakness, or that you’re not trying hard enough or don’t have enough willpower. It’s very important to know that depression can happen to anybody.
Q: TBI, anxiety, and chronic pain often go together. How do you guard against dangerous drug interactions associated with the multiple sedative medications commonly used to treat anxiety (benzodiazepines) and chronic pain (prescription opioids)?
A: In our programs, we tend to recommend against using sedatives chronically after TBI because of the risk for cognitive impairment, as well as the potential for abuse. If a person has cognitive deficits resulting from a TBI, there is a risk of accidental overdose if sedatives are prescribed. We typically tend to recommend non-sedative, non-hypnotic medications for anxiety, such as antidepressants and psychotherapy.
Q: Cognitive behavioral therapy (CBT) has been used to successfully treat patients with depression and TBI. How does it work?
A: CBT uses strategies to identify and challenge cognitive and behavioral patterns that are contributing to depression. In our research we found that focusing on behaviors may be particularly effective for TBI patients, who are often action-oriented young adults. A behavioral focus includes encouraging positive behaviors such as encouraging participation in pleasant activities and working to decrease avoidance behaviors that can result in social isolation. We also found that even people with moderate to severe cognitive problems from TBI people can benefit from the cognitive aspects of CBT, such as identifying and challenging negative thoughts.