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THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER TBI

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THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER TBI Olli Tenovuo MD, PhD Department of Neurology University of Turku, Finland Background TBI has long been an ... – PowerPoint PPT presentation

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Title: THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES AFTER TBI


1
THECLINICAL SPECTRUM OF CHRONIC PAIN SYNDROMES
AFTER TBI
  • Olli Tenovuo
  • MD, PhD
  • Department of Neurology
  • University of Turku, Finland

2
Background
  • TBI has long been an underestimated area in
    clinical medicine, especially in regard to its
    significance for public health.
  • There are still major gaps in our knowledge of
    some very central issues. One of these is the
    co-occurrence of chronic pain and TBI.

3
Background
  • The co-morbidity of chronic pain and TBI is
    highly complex ? clear diagnostic and treatment
    guidelines, applicable at an individual level,
    cannot be expected.
  • This should not hamper progression in research
    and clinical care of these patients.

4
The spectrum
  • Chronic pain syndromes after TBI
  • chronic headache
  • facial pain
  • neck pain
  • shoulder pain
  • pain in the extremities (painful hemisyndrome)
  • rare pain syndromes

5
Contents of the presentation
  • A clinical and diagnostically oriented review of
    the most important pain problems after TBI,
    especially
  • chronic headache
  • chronic facial pain
  • chronic neck pain
  • central pain

6
Chronic posttraumatic headache
  • The ICHD-II classification (2004)
  • Headache develops within 7 days after (mild -
    severe) head injury
  • Headache persists gt 3 months after the injury

7
The ICHD-II classification
  • 5.2.2 Chronic posttraumatic headache attributed
    to mild head injury
  • A. Headache, no typical characteristics known,
    fulfilling criteria C and D
  • B. Head trauma with at least one of the
    following
  • 1. Either no loss of consciousness or loss of
    consciousness for lt 30 mins duration
  • 2. GCS 13
  • 3. Symptoms and/or signs diagnostic of concussion
  • C. Headache develops within 7 days after head
    trauma or after regaining consciousness after
    head trauma
  • D. Headache persists for 3 months after head
    trauma

8
Problems in definition
  • The concepts of head injury and brain injury have
    been mixed
  • The definition of mild HI lacks the duration of
    posttraumatic amnesia as a criteria
  • within 7 days or after regaining consciousness
    in mild injury???
  • persists for 3 months but how often does it
    have to occur?

9
The ICHD-II classification
  • 5.2.1 Chronic posttraumatic headache attributed
    to moderate or severe head injury
  • A. Headache, no typical characteristics known,
    fulfilling criteria C and D
  • B. Head trauma with at least one of the
    following
  • 1. Loss of consciousness for gt 30 mins
  • 2. GCS lt 13
  • 3. Posttraumatic amnesia for gt 48 hrs
  • 4. Imaging demonstration of a traumatic brain
    lesion (cerebral hematoma, intracerebral and/or
  • subarachnoid hemorrhage, brain contusion, and/or
    skull fracture)
  • C. Headache develops within 7 days after head
    trauma or after regaining consciousness after
    head trauma
  • D. Headache persists for 3 months after head
    trauma

10
Problems in definition
  • The concepts of head injury and brain injury have
    been mixed
  • PTA gt 48 hrs why this limit??
  • Imaging demonstration of a traumatic brain
    lesion Is skull fracture a brain lesion?
    Axonal injury or oedema are not brain lesions?
  • Within 7 days what about PTA gt 7 days?
  • Persists for 3 months at which frequency?

11
And further critique
  • Why should the TBI severity be included in the
    criteria?
  • The time limits are artificial and do not base on
    any evidence
  • The role of frequent extracerebral causes
    (especially concomitant neck injury) has been
    neglected
  • - should the research of posttraumatic headache
    really be based on these criteria?

12
An alternative definition
  • Chronic posttraumatic headache
  • Headache that usually develops within 3 months
    after an injury to the head or neck and is not
    better explained with non-traumatic causes after
    a thorough clinical history and examination,
    including appropriate imaging and laboratory
    studies. After developing, the headache should
    occur at least weekly for at least 6 months.
  • A new official definition for clinical and
    research purposes should be made urgently,
    including the definition for various subtypes.

13
How common is chronic posttraumatic headache?
  • The figures have been very variable, depending on
    the study population, protocol and headache
    criteria
  • The available data suggest that headache follows
    head injury in 50 to 80 of patients acutely and
    continues in 20 to 30 1 to 2 years later (Couch
    JR, Lipton RB, Stewart WF, Scher AI. Head or neck
    injury increases the risk of chronic daily
    headache. A population-based study. Neurology
    20076911691177)

14
Subacutely
  • 100 sequential admissions with mild TBI (as
    defined by American Congress of Rehabilitation
    Medicine, 1993), and 100 matched minor injury
    controls with nondeceleration injuries
  • 15.34 of those with minor head injury continued
    to complain of persistent posttraumatic headache
    at 3 months compared to 2.2 of the minor injury
    controls
  • (Faux S, Sheedy J. A Prospective Controlled
    Study in the Prevalence of Posttraumatic Headache
    Following Mild Traumatic Brain Injury. Pain Med
    2008, Epub ahead of print)

15
And in the long run
  • A Norwegian study compared the prevalence of
    headache in a cohort with previous
    hospitalization for head injury (22 yrs earlier)
    and matched controls
  • In multivariate conditional regression analysis
    among 192 responding case/control pairs, there
    was no evidence of higher odds of headache gt 1
    day per month (odds ratio, OR 1.04, 95 CI
    0.561.92, p 0.90) compared with controls.
  • (Nestvold K, Staven M. Headache 22 Years after
    Hospitalization for Head Injury Compared with
    Matched Community Controls. Neuroepidemiology
    2007 29113120)

16
The type of posttraumatic headache
Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ,
Walker WC Characteristics and treatment of
headache after traumatic brain injury A focused
review. Am J Phys Med Rehabil 200685619627.
17
  • We performed a systematic literature review on
    this topic and found that many patients with PTH
    had clinical presentations very similar to
    tension-type headache (37 of all PTH) and
    migraine (29 of all PTH).
  • Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ,
    Walker WC Characteristics and treatment of
    headache after traumatic brain injury A focused
    review. Am J Phys Med Rehabil 200685619627.

18
The profile of posttraumatic headache
Lew HL, Lin P-H, Fuh J-L, Wang S-J, Clark DJ,
Walker WC Characteristics and treatment of
headache after traumatic brain injury A focused
review. Am J Phys Med Rehabil 200685619627.
19
Chronic posttraumatic headache
Periodic / daily
Episodic
Continuous
Cervical / occipital
Frontal, frontotemporal, ribbon-like, variable
Neck-derived headache
With cervical signs
Without cervical signs
Analgetics 3 days / week
No
Orofacial dysfunction
Psychogenic
Yes
Visual dysfunction
Medication overuse headache
Idiopathic
Hormonal insufficiency
20
Chronic episodic posttraumatic headache
  • Migrainous (with migrainous characteristics)
  • Neuritic (with neuralgic signs and localization)

21
Chronic periodic posttraumatic headache
  • Muscular source (with muscular signs and
    localization)
  • Migrainous (with characteristics of prolonged
    migraine)
  • Cervical (with cervical signs, precipitating
    factors, cervical / frontal localization)

22
Some important notes
  • The spectrum of acute and subacute posttraumatic
    headaches is much wider
  • In a minor but significant portion of patients,
    the clinical history, examination and
    consultations reveal no clear causes for the
    persisting headache.
  • In many of these, the headache clearly
    accompanies tiredness or fatigue. Treating a
    sleep problem or fatigue may offer a relief.

23
Some important notes continued
  • The often underdiagnosed post-traumatic hormonal
    insufficiency may also cause headache, and must
    be kept in mind as a treatable cause.
  • Cervicogenic headaches are underdiagnosed
    suggestive features
  • rotatory injury mechanism
  • acute neck pain and restricted movements
  • weakness, numbness or pain in the extremities
  • cervical pain and impaired mobility persist for
    weeks after the injury

24
Some important notes continued
  • Clinical signs of cervicogenic headache
  • asymmetrically impaired cervical mobility
  • pain or tingling produced by rotation or flexion
    extension
  • local tenderness in palpation of the C I-II
    vertebrae
  • Further evaluation should preferably happen with
    functional cervical MRI, which is able to show
    eventual disruptions of the alar or transverse
    ligaments

25
Kaale BR, Krakenes J, Albrektsen G, Wester K.
Head position and impact direction in whiplash
injuries associations with MRI-verified lesions
of ligaments and membranes in the upper cervical
spine. J Neurotrauma. 2005 Nov22(11)1294-302
26
Chronic neck pain after TBI
  • Is usually accompanied by headache, at least
    intermittently
  • May stem from bony or soft tissue injuries
  • The clinical assessment should include detailed
    injury reconstruction, skilled examination of the
    cervical function and neurological examination of
    the cranial nerves and upper extremities

27
Chronic neck pain after TBI
  • Sensory disturbances in the upper extremities or
    C I-II region should raise a suspicion of nerve
    root injury or posttraumatic syringomyelia
  • Imaging of traumatic lesions in the cervical
    spine requires expertise and normal results do
    not necessarily mean normal anatomy
  • An experienced physiotherapist or specialist in
    physical medicine is invaluable

28
Chronic facial pain after TBI
  • May have multiple aetiologies, such as
  • Trigeminal injury
  • Orofacial dysfunction
  • Sinus disturbance
  • Upper cervical lesions
  • Orbital lesions
  • Atypical facial pain

29
  • Irritation to structures innervated by the
    cervical sensory nerves can activate the
    trigeminal nucleus along with the
    trigeminovascular system and result in referred
    pain to the anterior or frontal aspect of the head
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