THE QUIZ: Chronic Pain and Traumatic Brain Injuries

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Traumatic brain injuries (TBI) and their resultant effects on cognitive function and mental health have been the focus of a great deal of attention recently as a result of increasing recognition of them among the military and athletes, especially football and hockey players. However, there has been much less awareness of chronic pain developing as a result of TBI.

1) Current research indicates approximately what percentage of people who suffer TBI develop chronic pain?

A. Fewer than 25%
B. 25% to 40%
C. 40% to 60%
D. More than 60%

2) The more severe the TBI, the more likely chronic pain will result.

A. True
B. False

3) No predictive factors have been identified for determining which people who experience TBI are most likely to develop chronic pain.

A. True
B. False

4) Headaches are the most common type of pain experienced by people who suffer with TBI. Which types of headache are most likely to occur?

A. Migraine
B. Tension-type
C. Mixed headaches with symptoms of both migraines and tension-type
D. Cluster
E. A,B, and C
F. All of the above

5) After headaches, the most common sites of chronic pain that develop as the result of TBI are:

A. Neck and back
B. Shoulders
C. Upper extremities
D. Lower extremities
E. All of the above
F. A, B, and C

6)

Regarding recommendations for treatment of chronic pain after TBI, which of the following is most accurate?

A. The current recommendation for headaches is to be treat them as you would treat headaches without an association with TBI.
B. As yet, there are no clear recommendations for the treatment of non-headache post-TBI pain.
C. Post-TBI non-headache pain is best treated the same as neuropathic pain conditions.
D. A and C

7) Findings indicate that if chronic pain related to TBI does not resolve after one year, there is virtually no chance it will ever resolve.

A. True
B. False

8) TBI sufferers with PTSD also appear to be more likely to have chronic pain.

A. True
B. False

9) The mechanisms for chronic pain following TBI have been identified.

A. True
B. False

10) Which of the following may be possible explanations for post-TBI pain?

A. Disruption in dopamine signaling due to injury to the dopaminergic centers in the brain
B. An inflammatory process involving the nervous system
C. Damage to neurons
D. Alterations in immune function
E. All of the above

Answers on the following page »

1. Answer: C. 40% to 60%

Studies indicate approximately 52% of civilian patients with TBI will have chronic pain, and 43% of military veterans have chronic pain as a result of service related TBI.¹

2. Answer: B. False

Up to now, there have been no research findings indicating that the development of chronic pain is correlated with the severity of the TBI.²

3. Answer: A. True

Predictive factors have yet to be identified. A variety of such factors have been proposed, but none has been found to be consistently predictive.²

4. Answer: E. A, B, and C

Migraine, tension-type, and mixed headaches appear to be the most common to develop as the result of TBI.³

5. Answer: E. All of the above.

Although it is commonly thought that the pain secondary to TBI is limited to the head and neck, research has shown that it can also be in the upper and lower extremities. Thus, any pain that develops after a TBI, no matter where the location of the pain is, should be considered as potentially resulting from the TBI.²

6. Answer: D. A and B

At present, it is recommended that post-TBI headaches be treated as one would treat the same types of headache without the occurrence of TBI. With regard to non-headache chronic pain following TBI, there is little research indicating the best treatment approaches.²

7. Answer: B. False

Longitudinal studies indicate that post-TBI pain can resolve even several years after its onset. As of yet, no factors that would predict which person’s pain is likely to resolve have been identified. Thus, there is always some possibility the pain will resolve but there is no guarantee of this, and it should not be depended on as likely to occur.²

8. Answer: A. True

There appears to be an association between the development of post-TBI chronic pain and of PTSD. However, whether this indicates that there may be some underlying mechanism of development shared by pain and PTSD or whether one might make the TBI patient more susceptible to developing the other is still unclear.³

9. Answer: B. False

Although multiple theories have been proposed, the mechanisms for the development of post-TBI pain have yet to be identified.²

10. Answer: E. All of the above

All of these have been proposed as possible mechanisms for the development of pain following TBI. As these are not mutually exclusive, it is quite possible that multiple mechanisms may be involved and that the importance of each may vary from patient to patient.^2,4,5

Disclosures:

Dr King is in private practice in Philadelphia.

References:

1. Nampiaprampi DE. Prevalence of chronic pain after traumatic brain injury: a systematic review. JAMA. 2008;300:711-719.

2. Irvine KA, Clark JD. Chronic pain after traumatic brain injury: pathophysiology and pain mechanisms. Pain Medicine. 2018;19:1315-1333.

3. Department of Veterans Affairs; Department of Defense. VA/DoD Clinical Practice Guidelines for the Management of Concussion-Mild Traumatic Brain Injury. 2016. https://www.healthquality.va.gov/guidelines/Rehab/mtbi/mTBICPGFullCPG50821816.pdf. Accessed February 13, 2019.

4. Bales JW, Wagner AK, Kline AE, et al. Persistent cognitive dysfunction after traumatic brain injury: a dopamine hypothesis. Neurosci Biobehav Rev. 2009;33:981-1003.

5. Gupta R, Sen N. Traumatic brain injury: a risk factor for neurodegenerative diseases. Rev Neurosci. 2016;27:93-100. ❒