Transcript Conservative management of pain after TBI

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 self-management
• 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
• Aerobic 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.
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
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Many treatment modalities available
Stretching
Strengthening
Ultrasound
TENS
Traction
Bracing & Assistive Devices
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Lumbar support
Knee braces
Cane
Walker
Acupuncture
Acupuncture
WHO, NIH Consensus Study
• Classified disease
processes according to
evidence for
acupuncture efficacy
• 2003
• Proven
• Needs further research
• Worth trying
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:
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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)
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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, non-organic
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:
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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
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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
• Choroidopathy, central
serous
• Colour blindness
• Deafness
• Hypophrenia
• Neuropathic bladder in
spinal cord injury
• Pulmonary heart disease,
chronic
• Small airway obstruction
• Irritable colon syndrome
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
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CPGS
Success
132 (34.1)
HFAQ
Success
195 (50.4)
Combined CPGS and HFAQ
Success
223 (57.6)
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Combined GCPS, HFAQ
Nonresponders
164 (42.4)
Responders
223 (57.6)
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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)
Conventional
Sham Acupuncture
Verum Acupuncture
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)