analgesic ladder in tbi pain managementbridgesnky.org/public/plunkett-heberling 2013 nky tbi conf...

2013 Seventh Annual NKY TBIConference

3/22/13

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Analgesic Ladder in TBIPain Management

Jim Plunkett, M.D.VA Medical Center/UC Dept of

PM&R2013 NKY TBI Conference

March 22, 2013

Chronic Pain

IASP definition “an unpleasant sensory or emotional

response to a stimulus associated with actualor potential tissue damage”

Pain “lasting longer than the anticipatedcourse of recovery” – often 3-6 months

Neurologic, physiologic, and emotionalcomponents ( suffering)

Nociceptive Pain

Noxious stimuli activating peripheralreceptors producing typical acute painalong a-delta and C fibers

Pin-prick or stab wound or stubbed toe Burn injury Fractures


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Neuropathic Pain

Pain associated with injury or disease ofperipheral nerves DM peripheral neuropathy Shingles ( PHN) Radiculopathy

Burning, shooting, lancinating pain

Allodynia, hyperpathia, central sensitization

Beginning to End: The Chronic Pain Cycle Pathology:-Muscle atrophy,

weakness;-Bone loss;-Immunocomprimise-Depression / Suicide

Less activeKinesophobiaDecreased

motivationIncreased

isolationRole loss

Disability

Pathophysiology of Maintenance:-Radiculopathy-Neuroma traction-Myofascial sensitization-Brain, SC pathology (atrophy, reorganization)

Psychopathologyof maintenance:-Encoded anxiety

dysregulation- PTSD

-Emotionalallodynia

-Mood disorder NeurogenicInflammation:- Glial activation- Pro-inflammatory

cytokines- blood-nerve barrier

dysruption

Acute injuryand pain

PeripheralSensitization:New Na+ channelscause lowerthreshold

CentralSensitization-Neuroplasticchanges

Gallagher RM, in Ebert & Kerns, 2010)


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PTSDN=232

68.2%2.9%16.5%

42.1%

6.8%

5.3%

10.3%

12.6%

TBIN=227

66.8%

Chronic PainN=277

81.5%

Prevalence of Chronic Pain, PTSD and TBI in a sample of340 OEF/OIF veterans

Lew, Otis, Tun et al., (in Press). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussiveSymptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD

WHO Analgesic Ladder 1986

Step 1: Non-opioids (tylenol +/- NSAID) +/- adjuvants

Step 2: “Weak opioids” + non-opioids +/- adjuvants

Step 3: “ Strong opioids” + non-opioids +/- adjuvants

Expanded Analgesic Ladder 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


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Ladder ( con’t)

Non-opioids Acetaminophen Aspirin

NSAIDS

Adjuvants

Muscle relaxants Anti-epileptic drugs ( AEDs) Anti-depressantsCorticosteroids

Narcotics

Pseudo-narcotics ( tramadol)Weak potency vs. Strong potency Short-acting vs. Long- actingOral vs. topical vs. transmucosal vs. IVCombination


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Invasive procedures

Basic Myofascial trigger point injections Intra-articular injections Botox – headache and spasticity Acupuncture Nerve blocks

Invasive procedures

Advanced: ( 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 pumpRhizotomy or myelotomyDeep Brain stimulation Thalatomy


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Cognitive/Behavioral therapies

Progressive relaxationGuided imagery Individual and Group therapyCognitive/behavioral therapy Biofeedback

Pain Categories

“Orthopedic” OA/DJD Muscles, tendons, ligaments

“Neuropathic” Myelopathy, radiculopathy Peripheral neuropathy

Complex/Central Pain

Categories

Above + Chronicity help guide treatmentOther factors – Secondary Gain

Workmen’s Comp, Tort claim, SSDI

Medical co-morbidities Traumatic Brain Injury

Age


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HeadacheEpisodic Headache•Characterize type•Abortive therapy

•Maximum 6 doses/week

Chronic Daily Headache•> 15 HA days per month•Analgesic rebound•Prophylaxis is key

Abortive

NSAIDs•GI side effects

IbuprofenNaproxen SodiumAspirin

Triptans•Contraindicated inpatients with CAD

CombinationMedications•Cognitive side effects•Risk of W/D

FioricetFiorinalMidrin

ProphylaxisOnset of action ~ 4 wks

Beta-blockers•Non-selective mayhave benefit onautonomic effects ofPTSD

Propranolol

Anti-depressants•May improve mood•Improves sleep

NortriptyllineAmitryptillineParoxetineFluoxetine

AEDS

•Neuropathic paingabapentin

•Mood labilityvalproic acidtopirimate

AlternativesPromethazineMetoclopramideProchloroperazineTizanidineNon-medicationTrigger point injectionOccipital nerve blockPhysical therapy

Avoid narcotics& Benzos

Drug InteractionsHeadacheDrug PTSD Drug Interaction

TricyclicAntidepressants SSRIs

1) Inc TCA levels2) Serotonin

syndrome

Triptans SSRIs SerotoninSyndrome*

Propranolol Prazosin Additive loweringof BP, orthostasis

TricyclicAntidepressants

Benzodiazepine Additive increasein sedation

Back to Ladder details

Activity modifications “RICE” + Lifting and positional limitations Work hours and work pacing Rotation of repetitive tasks Ergonomic adjustments Biomechanical optimization Graduated return to work


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Topical modalities Ice Heat Topical analgesics

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

CaneWalker incl. Rolling walker w/ fold-down

seatWheelchair ( manual vs. electric)

Scooter

Orthotics

Lumbar supportWrist 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


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PT + HEP

Stretching/ROM/soft tissue mobilization Strengthening – Isometric -> Isotonic Work or activity - specific training Plyometrics Basic or modified aerobic reconditioning

Walking/treadmill - graduated Bike riding – upright/recumbent Aquatic – based Cardiopulmonary parameters

Massage Therapy

Craniosacral techniques for TBI

Chiropractic

ManipulationModalities


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Basic Selfcare – Health habits

Obesity – diet Smoking AlcoholDrug abuse Sleep hygiene Stress management

Basic analgesics

Acetaminophen ( NTE 4000 mg/day) Hepatic caveats

ASA GI monitoring

NSAIDs Salicylates

Non-acetylated ( Salsalate, Disalcid, Trilisate) Propionic acids

Ibuprofen, Naproxen, ketoprofen, Oxaprasin Acetic acids

Indomethacin, diclofenac, sulindac, toradol Oxicams

Piroxicam Cox-2 Inhibitors

Celebrex Xyflamend – herbal - OTC


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Muscle relaxants Cyclobenzaprine ( TCA) Parafon forte, methocarbamol, carisoprodol Dantrium Baclofen Tizandine Diazepam

Caveat re sedation and liver function Soma – ( and valium) dependency

Neuropathic agents

Antidepressants TCA – ami/nortriptyline, trazodone,

desipramine SSRI’s: SNRI’s: venlafaxine, duloxetine

Neuropathic agents

Anti-epileptic drugs: Carbamazepine, oxcarbazepine Topiramate, Keppra Gabapentin ( Neurontin) Pregabalin ( Lyrica)

Watch for CNS SE, drug interactions esptegretol

LFT and WBC monitoring


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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


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Narcotics

Short-acting Oxycodone – schedule II Hydrocodone – schedule III-> II Meperidine ( Demerol) Hydromorphone ( Dilaudid)

• Avoid for chronic pain – rapid accommodation Morphine IR

Narcotics

Long-acting OxyContin Morphine SR, MS Contin Avinza, Opana Methadone Fentanyl patch or lollipop Tapentadol (Nucynta)

Narcotic SE

Common N/V Constipation – proactive bowel regimen Sedation *** Key to avoid in TBI** Itching Physiologic/psychological dependence Sweating Anorexia Myoclonus


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Narcotic SE

Myoclonus Dizziness/orthostasis Accommodation Respiratory suppression Cardiac dysrhythmia – methadone

Methadone also difficult to achieveequianalgesic dosing + occ idiosyncratic buildupw/ long ½ life > analgesic effect

Narcotic Issues

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

PTSDRe-experiencingAvoidanceSocial withdrawalMemory gapsApathy

MildTBI

Residua

Difficulty with decisionsMental slownessConcentrationHeadachesDizzyAppetite changesFatigueSadnessSuicidality

Altered ArousalSensitive to noiseConcentrationInsomniaIrritability

Depression

SubstanceUse (Poly)

Pain

Medication effectsPain


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Conservativemanagement of pain

after TBIRachel Heberling, MD

Cincinnati VA Medical CenterUniversity of Cincinnati

Why Conservative PainManagement in TBI?

Increased sensitivity to medications Increased difficulty managing medications,

especially prn’s Increased self-efficacy via self-

management Potentially decreased number of office

visitsCost-effective

Heat

Superficial heat: heating pad, hot shower,hot bath

Deep heat: ultrasound

Effective for pain relief, increased muscleflexibility

Not much evidence, but obviously effectivebriefly


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Cold

Superficial: Ice packsDeep: cold laser

Cold effective for pain relief and reducinginflammation, but contracts muscles

Unclear mechanism and efficacy of coldlaser

STRETCHING!

Muscle has viscoelastic properties Slow, deep stretch paired with deep

breathing necessaryMuscle properties change for ~10 hrs after

deep stretch

Evidence not compelling, but pain-reliefeffect of stretching is very obviousclinically

Stretching!


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Other types of Exercise

Aerobic exercise – has huge role indecreasing muscle tension andconsequent pain.

Strength training – some role indecreasing pain (e.g. core strengthening),but generally minimized until painbeginning to improve.

Meditation

Increasing base of evidence for the painrelief effects of meditation

Decreases stress Improved emotional acceptance of pain

Yoga

EXCELLENT choice for exercisemaintenance

Has role in decreasing active pain issuesas well.

Must start in beginner class!


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Advanced Yoga Class

Tai Chi

Becoming more popular topic of researchHave found that Tai Chi practice

decreases falls in the elderly Somewhat similar to yoga, but more

focused on gentle fluid movement, asopposed to deep prolonged stretch

Physical Therapy

Many treatment modalities available Stretching StrengtheningUltrasound TENS Traction


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Bracing & Assistive Devices

Lumbar support Knee bracesCaneWalker

Acupuncture

Acupuncture


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WHO, NIH Consensus Study

Classified diseaseprocesses according toevidence foracupuncture efficacy

2003

Proven Needs further research Worth trying

Diseases, symptoms or conditions for which acupuncturehas been PROVEN-through controlled trials-to be an

effective treatment:

Adverse reactions to radiotherapyand/or chemotherapyAllergic rhinitis (including hayfever)Biliary colicDepression (includingdepressive neurosis anddepression following stroke)Dysentery, acute bacillaryDysmenorrhoea, primaryEpigastralgia, acute (in pepticulcer, acute and chronic gastritis,and gastrospasm)Facial pain (includingcraniomandibular disorders)HeadacheHypertension, essentialHypotension, primary

Induction of labourKnee painLeukopeniaLow back painMalposition of fetus, correction ofMorning sicknessNausea and vomitingNeck painPain in dentistry (including dentalpain and temporomandibulardysfunction)Periarthritis of shoulderPostoperative painRenal colicRheumatoid arthritisSciaticaSprainStrokeTennis elbow

WHO Acupuncture and The NIH Consensus Study

Diseases, symptoms or conditions for which thetherapeutic effect of acupuncture has been shown but

for which FURTHER PROOF IS NEEDED: Abdominal pain (in acute

gastroenteritis or due togastrointestinal spasm)Acne vulgarisAlcohol dependence anddetoxificationBell’s palsyBronchial asthmaCancer painCardiac neurosisCholecystitis, chronic, with acuteexacerbationCholelithiasisCompetition stress syndromeCraniocerebral injury, closedDiabetes mellitus, non-insulin-dependentEaracheEpidemic haemorrhagic feverEpistaxis, simple (withoutgeneralized or local disease)

Eye pain due to subconjunctivalinjectionFemale infertilityFacial spasmFemale urethral syndromeFibromyalgia and fasciitisGastrokinetic disturbanceGouty arthritisHepatitis B virus carrier statusHerpes zoster (human (alpha)herpesvirus 3)HyperlipaemiaHypo-ovarianismInsomniaLabour painLactation, deficiencyMale sexual dysfunction, non-organic Ménière diseaseNeuralgia, post-herpetic



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Diseases, symptoms or conditions for which thetherapeutic effect of acupuncture has been shown but

for which FURTHER PROOF IS NEEDED:

NeurodermatitisObesityOpium, cocaine and heroindependenceOsteoarthritisPain due to endoscopicexaminationPain in thromboangiitis obliteransPolycystic ovary syndrome (Stein-Leventhal syndrome)Postextubation in childrenPostoperative convalescencePremenstrual syndromeProstatitis, chronicPruritusRadicular and pseudoradicularpain syndromeRaynaud syndrome, primary

Recurrent lower urinary-tractinfectionReflex sympathetic dystrophyRetention of urine, traumaticSchizophreniaSialism, drug-inducedSjögren syndromeSore throat (including tonsillitis)Spine pain, acuteStiff neckTemporomandibular jointdysfunctionTietze syndromeTobacco dependenceTourette syndromeUlcerative colitis, chronicUrolithiasisVascular dementiaWhooping cough (pertussis)


Diseases, symptoms or conditions for which there areonly individual controlled trials reporting some

therapeutic effects, but for which acupuncture is WORTHTRYING because treatment by conventional and other

therapies is difficult:

Chloasma

Choroidopathy, centralserous

Colour blindness

Deafness

Hypophrenia

Neuropathic bladder inspinal 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


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GERAC – Design

10 sessions over 10 weeks regardless ofgroup

5 additional sessions for partialresponders (>10%, <50% improvement)

Limited communication with acupuncturistto avoid unblinding

Allowed NSAID for rescue, max twiceweekly.

GERAC - ResultsTable 4. Primary Outcome: Pairwise Comparisonof Treatment Response 6 Months After Randomization

Treatment Response Intergroup Difference P ValueGroup 1 vs group 347.6 (42.4 to 52.6) vs 20.2 (13.4 to 26.7) 0.00127.4 (23.0 to 32.1)

Group 2 vs group 344.2 (39.2 to 49.3) vs 16.8 (10.1 to 23.4) 0.00127.4 (23.0 to 32.1)

Group 1 vs group 2 3.4 (−3.7 to 10.3) 0.3947.6 (42.4 to 52.6) vs44.2 (39.2 to 49.3)

GERAC - Results Treatment Response After 6 Months Conventional Sham Acupuncture Verum Acupuncture CPGS Success 132 (34.1) 197 (50.9) 229 (59.2) HFAQ Success 195 (50.4) 251 (64.9) 281 (72.6) Combined CPGS and HFAQ Success 223 (57.6) 277 (71.6) 304 (78.5)

Combined GCPS, HFAQ Nonresponders 164 (42.4) 125 (32.3) 112 (28.9) Responders 223 (57.6) 262 (67.7) 275 (71.1)

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)


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