Pain and the Injured Brain: A Biopsychosocial Conceptualization. Michael F. Martelli, PhD and Keith Nicholson PhD

Transcription

1 In Press, Brain Injury Professional Pain and the Injured Brain: A Biopsychosocial Conceptualization Michael F. Martelli, PhD and Keith Nicholson PhD Introduction Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Merskey and Bogduk, 1994). Acute pain usually occurs in response to identifiable tissue damage or noxious event, has a time-limited course and any needed treatment targets underlying pathology. Chronic pain persisting beyond 6 months is often not associated with obvious tissue damage or pathology and may be characterized by anxiety, maladaptive protective responses or pain behaviors, protracted medication use, minimally effective medical services, marked behavioral or emotional changes and restrictions in daily activities. Painrelated avoidance behaviors can result in a self-perpetuating disability pattern; as pain persists, it becomes increasingly recalcitrant and treatment goals refocus on improved coping with pain and concomitants (Martelli et al., 2004, 2007). Increasing evidence associates persistent pain with peripheral and/ or central sensitization effects involving hyper-responsiveness in components of the pain system (Zasler et al, 2007; Nicholson & Martelli, 2004, 2006). An association between post-traumatic stress reactions and development of chronic pain suggests that uncontrollable pain after physical injury and anticipated pain (Wager et al, 2004; Porro et al, 2002) can represent a core trauma producing post-traumatic stress symptomatology and/or perpetuating it (Hart et al, 2003). Pain is a multidimensional subjective experience mediated by emotion, attitudes and other perceptual influences. Variability in pain responses is expected and appears to reflect complex biopsychosocial interactions between genetic, developmental, cultural, environmental and psychological factors (Gatchel & Turk, 1999). Important distinctions

2 between pain and suffering, impairment and disability and presentations ranging from possibly exaggerated suffering or disability to a belle indifference and absence of distress or interference despite high apparent pain intensity reflect the variability in response to pain problems and the importance of always considering both psychological and organic factors in the presentation of any chronic pain patient (Nicholson & Martelli, 2004, 2006; Zasler & Martelli, 2002). Complex pain presentations, especially when intractable or functionally disabling, acute or chronic, warrant referral to pain management specialists or specialty interdisciplinary pain programs. Competent, specialized, early intervention offers the greatest hope of facilitating adaptation to pain. Notably, the requirement for specialized assessment and management of pain has been incorporated into the prevailing standards of healthcare practice in the United States, while psychological assessment is a required element of pain treatment programs accredited by the Commission on Accreditation of Rehabilitation Facilities (Martelli, Nicholson, et al, 2007). Pain can be triggered by sensory inputs (e.g., acute) or independently (e.g., chronic) from sensitization effects or hyper-responsiveness in peripheral or central components of the medial pain system and related limbic structures (Zasler et al, 2007). Central pain control processes seem to encompass the cognitive-evaluative, motivationalaffective, and sensory-discriminative systems that characterize the pain response. The pain system is intimately related to other systems in the brain (e.g., motor, mnemonic, and social). TBI, cranial trauma and cervical whiplash injuries are all associated with a high comorbidity of chronic pain problems. Headache is the primary complaint in surveys of postconcussion syndrome (e.g., Nicholson & Martelli, 2004, 2006). Posttraumatic headache (PTHA) frequency in the immediate post accident period has been reported to be as high as 90%, with problems continuing beyond 6 months in as many as 44% of patients (Martelli,

3 Nicholson, Zasler, 2007). In addition to headache, many other pain problems may follow trauma, including back pain, complex regional pain syndrome (CRPS), and fibromyalgia, among others. Although PTHA problems are common, most studies report greater head and other pain problems in mild versus more severe TBI (Nicholson & Martelli, 2004, 2006; Zasler and Martelli 2002). Mahmood et al (2004) reported that while severe TBI is more likely to produce subcortical damage and reduce pain experience, mild TBI is associated with increased pain and sleep disturbance and that sleep disturbance is associated with frontal hypoactivation that especially when associated with depression heightens vulnerability to cognitive dysfunction. TBI, Chronic Pain and Neuropsychological Dysfunction There is increasing recognition of the disruptive effect pain may play in symptom presentation after TBI, including cognitive complaints (Nicholson & Martelli, 2004, 2006; Hart et al., 2000, 2003; Martelli et al, 2004, 2007). Available evidence from acute, as well as chronic animal and human pain studies involving experimental, clinical and neurophysiological studies strongly supports the conclusion that pain and pain-related symptomatology, independent of TBI or neurological disorder, can and often do produce impairment of cognitive functioning as assessed on neuropsychological and functional tests, especially on measures of attentional capacity, processing speed, memory, and executive functions (Martelli, Nicholson, Zasler, 2007). Recent reviews have also indicated that the associated symptoms of chronic pain, singly and in combination, may be more important than pain severity in producing cognitive and other impairment, including hyperalgesic changes and disruption of serotonergic and opioidergic processes (Pilcher & Huffcutt, 1996). Cognitive impairment in chronic pain patients has been associated with sleep disturbance / partial sleep deprivation, major depression, mood change/emotional distress, medication use,

4 somatic preoccupation and pain catastrophization and perceived interference with daily activities that are potential sources of chronic stress (Hart et al, 2000, 2003; Nicholson & Martelli, 2004, 2006; Mooney et al, 2005; Kunderman et al, 2004). Chronic pain and its concomitants can complicate the symptom picture in TBI. PTHA and associated problems can present a differential diagnostic challenge especially in cases of persistent sequelae following milder TBI, as well as complicate neuropsychological assessment when untreated and/or contribute to, exacerbate or maintain symptoms associated with TBI. This evidence provides strong support for the argument that resolution of the post-concussive syndrome and successful adaptation to residual sequelae frequently relies on successful coping with post-traumatic craniocervical pain and associated symptomatology. Assessment of Post-traumatic Headache Anticipation of pain activates cortical networks similar to pain itself (Wager et al, 2004; Porro et al, 2002). This highlights a complex, multidimensional, subjective perceptual pain process comprised of behavioral, affective, cognitive and sensory components. Hence, a comprehensive, biopsychosocial assessment is considered the standard of care when pain is chronic (Gatchel, Turk, 1999). In addition to medical findings, pain assessment should address self-report, via interview of patient, relevant others and use of appropriate assessment instruments, in the following areas: (1) Pain onset, location, intensity level, duration, course, quality /characteristics; (2) Affective and autonomic stress related effects (including psychophysiological assessment as indicated); (3) Pain behaviors, environmental effects / responses, specific effect on mood, activity, cognition, affect, sleep, appetite, irritating / relieving factors, etc.; (4) Medications and effects; (5) Beliefs about the pain condition; (6) Coping strategies and effectiveness; (7) Psychosocial context and social responses to pain; (8) Personality and psychoemotional status and adjustment, including general

5 coping, specific pain coping and how these affect or are affected by pain; (8) Activity, level of function / disability, quality of life, including current activities, pain related changes. See Martelli, Nicholson, Zasler (2007) for a survey of useful pain assessment instruments (link: at including ones for special populations. These are intended to be integrated with a thorough history taking, interview (patient, relevant others) and examination of relevant medical and health records. Included are measures of response bias or tendency to report or present pain / related disability inaccurately. This is important given the nature of pain (avoidance is a reflexive response), frequent forensic contexts, frequent pain related anxieties (fear of re-injury, avoidance of unpleasant situations) and possible dependency or avoidance personality traits, among other factors. See Martelli, Nicholson, Zasler et al (2007) for a thorough analysis and strategy for this challenging task. Behavioral and Psychological Management of Pain Pain management parallels pain assessment with treatment evolving over time from (1) analgesia; promoting healing and/or correcting pathophysiology; minimizing physical, cognitive or emotional distress reactions and preventing chronification, i.e., peripheral or CNS sensitization effects, to (2) improving adaptation and reducing functional disability. Comprehensive biopsychosocial assessment provides the framework for individually tailored treatment interventions and recommendations. Behavioral and psychological treatment interventions in persons with chronic post traumatic headache include individualized interventions that follow from the biopsychosocial assessment that provides a treatment framework, defines goals, expectations and sequences and provides psychoeducational information about the particular type of chronic pain and rationale for treatment (Martelli, et al, 2004, 2007).

6 Specific outcome studies that examine PTHA treatments are recently emerging. These are demonstrating the clear phenomenological similarities in clinical presentation and treatment response of PTHA compared to non-traumatic headache disorders. Martelli et al (2004, 2007) reviewed evidence supporting the utility of behavioral interventions for PTHA that include patient education, biofeedback, relaxation training, operant behavioral therapies, cognitive behavioral treatments, social, assertiveness, stress management and coping skills training. They noted that in cases of posttraumatic pain: (a) the severity and frequency of pain attacks and chronic pain-related sequelae such as coping abilities, depression, and anxiety may be significantly improved by combined behavioral treatment protocols; (b) supportive counseling that begins early after trauma and is continuous results in better patient response; and (c) combination medical and behavioral treatments increase likelihood of benefit. Several authors have systematically reviewed evidence supporting the efficacy of behavioral interventions for chronic pain that includes chronic headache and posttraumatic headache. Kröner-Herwig s (2009) review confirmed efficacy of behavioral treatment outcomes for chronic back pain, headache, fibromyalgia, and temporomandibular pain. Lake (2001), found that controlled studies of cognitive behavioral therapies (CBTs) for migraine, such as biofeedback and relaxation therapy, had a prophylactic efficacy of about 50%, roughly equivalent to propranolol, while the combination of behavioral therapies greatly increased efficacy. Rains et al (2005) note that meta-analytic reviews have consistently shown behavioral interventions (relaxation training, biofeedback, cognitive-behavioral therapy, and stress-management training) to yield 35% to 55% improvements in migraine and tension-type headache. Finally, supportive evidence now includes randomized clinical trials (e.g., Thorn et al, 2007) and the interesting finding of Ruff et al (2009) findings that a combined behavioral (sleep hygiene counselling) pharmacologic (prazosin) treatment effectively

7 improved sleep and decreased average frequency and intensity of PTH by 66% and improved cognitive assessment scores with results maintained at 6 months. Conclusions and Future Directions The assessment and treatment of chronic pain associated with TBI is a challenging process. Pain and its concomitants can have a more disabling effect across a wider range of functions than brain injury itself, particularly when mild. Available evidence strongly supports the conclusion that resolution of the post concussive syndrome and successful adaptation to residual sequelae frequently relies on successful coping with PTHA and associated symptomatology. Early, competent, specialized intervention offers the greatest hope of facilitating adaptation to pain. Complex or persistent pain presentations warrant referral to pain management specialists or specialty interdisciplinary pain programs. Biopsychosocial assessment and treatment strategies have emerged as the standard of care in chronic pain. The most promising current treatment interventions are combination treatments that are holistic in nature and target the patient's reaction to pain within his/her daily life and ability to exercise self-control. Multicomponent treatment packages are currently the preferred treatment choice for chronic pain generally and especially when it accompanies TBI (Martelli, et al, 2004, 2007). Early, competent, specialized intervention that includes education and combination medical and behavioural interventions directed at simultaneously improving adaption to PTH and improving its associated symptoms of sleep disturbance, emotional distress and depression, is indicated. References 1. Campbell JK. Penzien DB. Wall EM, Evidence-based guidelines for migraine headache: behavioral and physical treatments. April 25, http: // /professionals/practice/pdfs/g pdf. Accessed January Gatchel RJ Turk DC (Eds.): Psychosocial Factors in Pain. New York: The Guilford Press, 1999.

8 3. Hart RP. Martelli MF. Zasler ND., Chronic pain and neuropsychological functioning. Neuropsychol Rev, 10(3): , Hart RP. Wade JB. Martelli MF: Cognitive Impairment in Patients with Chronic Pain: The Significance of Stress. Current Pain and Headache Reports. 7: Kröner-Herwig B., Chronic Pain Syndromes and Their Treatment by Psychological Interventions. Curr Opin Psychiatry, 22(2): , Kundermann B. Krieg JC. Schreiber W. Lautenbacher S., The effect of sleep deprivation on pain. Pain Res Manag, 9(1):25-32, Lake AE, Behavioral and nonpharmacologic treatments of headache. Med Clin North Am, 85(4): , Mahmood O. Rapport LJ. Hanks RA. Fichtenberg NL., Neuropsychological performance and sleep disturbance following traumatic brain injury. J Head Trauma Rehabil, 19(5):378-90, Martelli MF Nicholson K Zasler ND: Psychological Approaches to Comprehensive Pain Assessment and Management Following TBI. In: Brain Injury Medicine: Principles & Practice. ND Zasler DI Katz RD Zafonte (Eds.) Demos, New York. Pages , Martelli MF Nicholson K Zasler ND Bender MC: Assessment of Response Bias in Clinical and Forensic Evaluations of Impairment Following Brain Injury. In: Brain Injury Medicine: Principles & Practice. ND Zasler DI Katz RD Zafonte (Eds.) Demos, New York. Pages , Martelli MF. Zasler ND. Nicholson K. Bender MC., Psychological, neuropsychological and medical considerations in the assessment and management of pain. J Head Trauma Rehabil, 19(1):10-28, Merskey H Bogduk N (Eds.): Classification of Chronic Pain. 2 nd Ed. Seattle: IASP Press, Mooney G. Speed J. Sheppard S., Factors related to recovery after mild traumatic brain injury. Brain Injury, 19(12):975-87, Nicholson K Martelli M. The confounding effects of pain, psychoemotional problems or psychiatric disorder, premorbid ability structure, and motivational or other factors on neuropsychological test performance. In Psychological Knowledge For Court: PTSD, Chronic Pain and TBI. G Young A Kane K Nicholson (Eds.) Springer, New York, NY. Pages , 2006.

9 15. Nicholson Kl Martelli MF., The problem of Pain. J Head Trauma Rehabil, 19(1):2-9, Pilcher JJ. Huffcutt AL., Effects of sleep deprivation on performance: A meta analysis. Sleep, 19: , Porro CA. Baraldi P. Pagnoni G, et al., Does anticipation of pain affect cortical nociceptive systems? J Neurosci15;22(8): , Rains JC. Penzien DB. McCrory DC. Gray RN., Behavioral headache treatment: history, review of the empirical literature, and methodological critique. Headache, May;45 Suppl 2:S92-109, Ruff RL. Ruff SS. Wang XF., Improving sleep: initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. J Rehabil Res Dev.;46(9): , Thorn BE. Pence LB. Ward LC. et al: A randomized clinical trial of cognitive behavioral treatment targeted at the reduction of catastrophizing in chronic headache sufferers. Journal of Pain, 68(12), , Wager TD. RillingJK. Smith EE., et al., Placebo-induced changes in FMRI in the anticipation and experience of pain. Science, 303: , Zasler N.D Horn LJ Martelli MF Nicholson K: Post-Traumatic Pain Disorders: Medical Assessment and Management. In: Brain Injury Medicine: Principles & Practice. ND Zasler DI Katz RD Zafonte (Eds.) Demos, New York. Pages , Zasler ND Martelli MF: Post-traumatic headache: Practical approaches to diagnosis and treatment. In Pain Management: A Practical Guide for Clinicians, 6th edition. : RB Weiner (Ed.). St. Lucie Press, Boca Ratan, FL. Pages , About the Authors: Michael F. Martelli, PhD directs Rehabilitation Neuropsychology at Tree of Life, a residential & transitional neurorehabilitation facility. He has 25 years of experience providing specialized, holistic assessment & treatment services, academic appointments, a diplomate in pain management, serves on editorial review and brain injury related

10 boards, is a past President of the Brain Injury Assoc. of VA & has written & lectured widely in areas of rehabilitation, psychology, neuropsychology, pain and disability. Keith Nicholson, Ph.D., is a psychologist with extensive clinical experience working with many different patient populations. He obtained his Ph.D. in Clinical Neuropsychology from the University of Victoria and, since then, has worked at the University Health Network in Toronto, Ontario in addition to working at several community clinics and maintaining a private practice. He has particular interest in the psychology of chronic pain and clinical neuropsychology.