Self-Reported Pain and Pain Management Strategies Among Veterans With Traumatic Brain Injury: A Pilot Study

Transcription

1 MILITARY MEDICINE, 180, 8:863, 2015 Self-Reported Pain and Pain Management Strategies Among Veterans With Traumatic Brain Injury: A Pilot Study Paul R. King, PhD*; Gregory P. Beehler, PhD, MA* ; Michael J. Wade, MS ABSTRACT Reports of chronic pain such as headache, back and neck pain, and other musculoskeletal conditions are common among veterans with history of traumatic brain injury (TBI). This pilot study investigates self-reported pain and pain management strategies in a sample of veterans in postacute recovery from TBI. Participants included 24 outpatients with history of mild-to-moderate TBI who completed a series of self-report measures by mail, including the Pain Outcomes Questionnaire, the Pain Symptom Survey pain scale, and a detailed background survey. Seventy-nine percent of veterans surveyed reported frequent experiences with pain, typically headache, lower back, and joint pain of moderate severity. Two-thirds reported multiple pain locations, and more than half reported multiple concurrent mental health concerns, most frequently depression and post-traumatic stress disorder. Several different pain self-management strategies were identified with highly variable effects, though better perceived pain outcomes were reported with regular use of exercise and antidepressants. Many participants identified significant concerns regarding reinjury. Results suggest that opportunity exists for mental health professionals to address common anxieties pertaining to reinjury and to deliver concurrent interventions for chronic pain and affective disturbance. INTRODUCTION Complaints of pain are common in patients with history of traumatic brain injury (TBI). 1 In the acute phase of TBI, pain issues may stem from a variety of intra- and extracranial sources such as damage to skin, bone, joints, nerves, and connective tissues. Chronic pain complaints among patients with TBI are also common and may include headache, musculoskeletal pain, and neuropathic pain. 2 A wide range of pain complaints have been documented among civilian patients with mild TBI (mtbi) at more than 2 years postinjury, many of whom identify multiple pain locations. 3 A number of population-specific factors are present among military veterans with and without TBI history, including high base rates of chronic pain, blast exposure, and other physical and affective comorbidities such as post-traumatic stress disorder (PTSD). 4 7 Retrospective reviews of veterans records have found generally high rates of headache and musculoskeletal pain among veterans with mtbi and persistent postconcussive symptoms, though some studies report that nonheadache pain occurs at rates similar to non-head-injured controls. 5,6 Nonetheless, several reviews highlight potential challenges of assessing and treating symptoms in the context of co-occurring conditions such as PTSD. 8,9 In particular, *Center for Integrated Healthcare, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY School of Public Health and Health Professions, University at Buffalo, The State University of New York, 3435 Main Street, Buffalo, NY School of Nursing, University at Buffalo, The State University of New York, Buffalo, 3435 Main Street, Buffalo, NY Center for Integrated Healthcare, Syracuse VA Medical Center, 620 Erie Boulevard West, Syracuse, NY The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. Government. doi: /MILMED-D the presence of pain can confound assessment and treatment of other potentially TBI-related concerns given its overlap with common postconcussive-like symptoms, such as fatigue, sleep disruption, and somatosensory complaints. 10 Key clinical recommendations for the treatment of veterans with TBI and pain have primarily revolved around conducting comprehensive interdisciplinary evaluation, headache management, and ongoing monitoring consistent with extant but separate practice guidelines for addressing mtbi, chronic pain, and PTSD. 11,12 Despite the relative increase in attention to the topic in recent years, significant gaps in knowledge exist with regard to both the efficacy and effectiveness of pain management interventions in veterans with history of TBI, as well as what self-management strategies are employed among those who experience chronic pain. 13 The present pilot study therefore aims to explore reports of pain and use of pain self-management strategies in a cross-sectional sample of veterans with TBI history who received Department of Veterans Affairs (VA) care for their injuries. METHODS Participants Participants in this pilot study were part of a larger mixed methods investigation of treatment experiences and engagement of veterans with TBI. Potential participants were identified using the VA Veterans Integrated Service Network 2 (Upstate New York) electronic medical record database which contains information such as patient demographics and encounter codes. Veterans were considered eligible for recruitment if they were active VA primary care patients at the study site, had attended at least one appointment for treatment pertaining to TBI or persistent postconcussive symptoms (ICD codes , 854, and 310.2) between 2009 and MILITARY MEDICINE, Vol. 180, August

2 2013, and were between ages 18 and 65. The exclusion criterion was severe cognitive impairment. Measures Background Survey A detailed background survey was developed for this study by the authors to gather information on participant demographics, health behaviors, health-related quality of life (QOL), general health care practices, and experiences with pain and pain management strategies. Frequency and effectiveness of pain management techniques were rated on 4-point Likert-type scales with frequency values ranging from daily use (1) to once every few months (4) and effectiveness values ranging from not very (1) to very effective (4). Pain Symptom Survey (PEG) The PEG 14 is a 3-item pain assessment derived from the Brief Pain Inventory 15 that has been validated for use with ambulatory VA patients. The PEG gauges patients average pain intensity (P), impact on their enjoyment of life (E), and interference with general daily activities (G). Items are rated on a 0 to 10 scale, with the total score calculated by averaging the values of individual items. Pain Outcomes Questionnaire (POQ) The 20-item POQ 16 prompts patients to rate pain-related cognitions and functions on a 0 to 10 scale. Sample items probe the extent to which pain interferes with patients ability to walk or climb stairs, self-esteem and mood, and concerns regarding risk for reinjury. The total score is calculated by summing the values of five subscales: pain-related impairment in activities of daily living (ADL), fear, mobility, negative affect, and vitality. A sixth subscale is based on a report of average pain over the past week. Procedures Three-hundred eighty-two veterans were deemed eligible for screening. Before telephone screening, study staff mailed introductory letters to 326 eligible veterans within the study window to describe the project and procedures to opt-out or volunteer for participation. These letters were mailed in waves until the minimum recruitment target for the parent study was met. Thirty-three candidates opted-out in advance of a screening call. Screening phone calls reviewed the study and probed capacity to consent to research and communication skills. In the event of questionable consent capacity or communication concerns, a licensed psychologist interviewed the candidate to assess communication skills and gauge decision-making capacity. Forty-six eligible and interested veterans were mailed enrollment packets which summarized the study, detailed consent procedures, and included the measures described above along with a postage-paid return envelope. Only one potential recruit was excluded for diminished capacity. Participants were compensated for their time upon completing the study. All procedures were Institutional Review Board-approved. Analysis Background survey and self-report data were coded and entered into an electronic database, which was later reviewed for accuracy. Descriptive and nonparametric statistics were calculated based on self-reports of racial/ethnic background, age, etc., and frequencies of endorsed symptoms. RESULTS Sample Descriptive Statistics Twenty-four participants (52.2% response rate) returned complete study materials. As shown in Table I, participants TABLE I. Participant Demographics Variable n (%) or Mean (SD) Age Mean (SD) 44.2 (12.9) Male n (%) 21 (87.5) Race/Ethnicity n (%) Asian/Asian American 1 (4.2) Caucasian 20 (83.3) Hispanic or Latino 1 (4.2) Multiethnic 1 (4.2) Relationship Status n (%) Divorced 3 (12.5) Living With Partner 1 (4.2) Married 14 (58.3) Separated 1 (4.2) Single, Never Married 5 (20.8) Vocational Status n (%) Attending School (Full or Part-Time) 5 (20.8) Employed (Full-Time, Part-Time, Volunteer) 10 (41.7) Employed and Attending School 1 (4.2) Unemployed 12 (50.0) Educational Background n (%) Less Than High School 1 (4.2) High School or GED 2 (8.3) Some College or Associate s Degree 15 (62.5) Bachelor s Degree 2 (8.3) Some Graduate School 1 (4.2) Graduate Degree 3 (12.5) Medical Provider n (%) VAMC or CBOC 19 (79.2) Both VA and Community 5 (20.8) Mental Health Provider n (%) VAMC or CBOC 19 (79.2) Both VA and Community 2 (8.3) Mental Health Diagnoses n (%) Alcohol or Substance Abuse 5 (20.8) Generalized Anxiety 5 (20.8) Depression 17 (70.8) PTSD 16 (66.7) Last Treatment Received for TBI n (%) Approximately 1 Month or Less 4 (16.7) Approximately 1 Month to 1 Year 9 (37.5) >1 Year 7 (29.2) Missing 4 (16.7) CBOC, VA Community Based Outpatient Clinic; TBI, Traumatic brain injury; VA, Department of Veterans Affairs; VAMC, VA Medical Center. 864 MILITARY MEDICINE, Vol. 180, August 2015

3 were primarily male (87.5%), Caucasian (83.3%), and married (58.3%), with an average age of 44.2 years (SD = 12.9). Fifty-eight percent were working and/or attending school, with the remainder unemployed, primarily because of subjective or objective disability (66.7%). The majority of participants used VA services exclusively (79.2%), though a small proportion used both VA and community services for medical (20.8%) and mental health care (8.3%); only three participants were nonusers of mental health services. Depression and PTSD were frequently reported, and 54.2% reported two or more concurrent mental health concerns. Pain and Health-Related QOL Table II summarizes pain and health-related QOL ratings. The majority of participants rated their overall physical TABLE II. Pain and Health-Related Quality of Life Variables Variable n (%) or Mean (SD) Reported Current Physical Health n (%) Poor 2 (8.3) Fair 4 (16.7) Average 8 (33.3) Good 5 (20.8) Very Good 4 (16.7) Excellent 1 (4.2) Reported Pain Frequency n (%) Not Regularly 5 (20.8) 1 2 Days/Week 4 (16.7) 3 4 Days/Week 3 (12.5) 5 6 Days/Week 3 (12.5) 7 Days/Week 9 (37.5) PEG Mean (SD) 4.3 (2.8) P Average Pain Past Week 4.3 (2.5) E Pain Interferes With Enjoyment 4.3 (3.1) G Pain Interferes With General Activity 4.3 (3.2) POQ Mean (SD) 56.5 (28.3) ADL Subscale 2.2 (3.8) Fear Subscale 9.3 (5.6) Mobility Subscale 12 (11.7) Negative Affect Subscale 17.8 (9.4) Pain Subscale 3.9 (2.5) Vitality Subscale 14.8 (6.4) Types of Pain n (%) Head/Headache 15 (62.5) Upper Back 6 (25.0) Lower Back 15 (62.5) Neck 10 (41.7) Joints 13 (54.2) Other 6 (25.0) Headache Only 1 (4.2) Musculoskeletal Only 4 (16.7) Headache + Musculoskeletal Pain 14 (58.3) Number of Pain Locations n (%) 0 5 (20.8) 1 3 (12.5) 2 2 (8.3) 3 4 (16.7) 4 5 (20.8) 5 5 (20.8) ADL, Activities of Daily Living; PEG, Pain Symptom Survey; POQ, Pain Outcomes Questionnaire; TBI, Traumatic brain injury. health as average (33.3%) or better (41.7%), though most (79.2%) reported regular weekly experiences with pain. Only about 13% reported being pain-free during the week before study participation, based on two average pain items from PEG and POQ. The average overall PEG rating was 4.3 (SD = 2.8), signifying a moderate level of pain, with average weekly pain and levels of interference with enjoyment and general activity rated similarly. POQ reports (displayed in Fig. 1) yielded similar average pain ratings (M =3.9,SD= 2.5). Pain type was most frequently attributed to headache and lower back pain (62.5% each), joint pain (54.2%), and neck pain (41.7%). Though most reported a decrease in QOL subsequent to their TBI (70.8%) and fairly consistent reports of moderate levels of current pain, the majority rated their current QOL as average (16.7%) or better (62.5%); four participants rated their QOL as fair, and only one as poor. Most (79.2% 83.3%) denied disruptions in basic ADLs such as bathing, using the bathroom, and grooming. A substantial portion of the sample reported significant worry about reinjury, with 62.5% rating this item at 6 or higher on a 10- point scale (0 = not at all ), and 33.3% reporting that they worried about reinjury all the time (item rated as a 10 ). Pain Management Participants reported a wide range of pain management strategies with varied frequency and effectiveness. Nonopioid medications and exercise were the most commonly endorsed approaches (91.2% each), followed by rest (79.2%). Less frequently used were heat therapy (54.2%), antidepressants (45.8%), and opioids (41.7%). Topical analgesics, biofeedback (16.7% each), and corticosteroids (4.2%) were least frequently reported. Four of 10 individuals who used opioid analgesics reported daily use. The only significant associations between frequency of use and effectiveness were observed for exercise (p = 0.022) and antidepressants (p = 0.039) (Fig. 2). DISCUSSION In this pilot study, we explored current pain reports and use of pain management strategies in a small, cross-sectional sample of veterans with TBI history as part of an on-going mixed methods investigation regarding knowledge, perception of symptoms and symptom management, and experiences in treatment. Our findings showed moderate levels of chronic pain across various stages of postacute TBI recovery. Well over half of our sample reported a pain frequency of at least 3 days per week, with more than one-third reporting a daily pain experience, and two-thirds reporting two or more chronic pain locations. Consistent with previous research, 1,6 the most frequently endorsed types of pain pertained to headache, back pain, and other musculoskeletal/joint pain. However, it should be noted that pain complaints in this sample were not necessarily attributable to TBI, though factors such as the number and MILITARY MEDICINE, Vol. 180, August

4 FIGURE 1. Pain Outcomes Questionnaire (POQ ratings.boxes represent interquartile range for POQ item ratings, with means (darkened circle) embedded within; whisker length is 1.5 times the interquartile range; hollow circles indicate outliers. severity of injuries may have played a role. Other potential correlates included the slightly older age of our sample, mental health concerns such as anxiety and depression, and other medical conditions or injuries for which we did not control. Exercise, nonopioid analgesics, and rest emerged as the most frequently used pain self-management strategies reported. Indeed, exercise in the context of a graded return to preinjury activity levels is a frequent feature of treatment, 17 and more frequent use of exercise was associated with greater perceived benefit. Other relatively common pain management strategies included heat therapy, antidepressants, and opioid analgesics, though of these strategies, only regular use of antidepressants was associated with greater benefit. Although most participants reported feeling that it would generally be safe to exercise, the majority reported significant concerns pertaining to reinjury as well as low to moderate limitations in mobility. Low but consistent levels of anxiety and depression, and moderate or worse difficulties with concentration and tension were also frequently reported. Our results are potentially pertinent to clinical practices in several ways. Most participants in our study reported multiple concurrent pain locations, suggesting the need for health care providers to be prepared to manage pain of various etiologies (i.e., headache, neuropathic, and musculoskeletal) in the context of other comorbid concerns. Our findings also suggest that 10 of 14 possible pain management strategies included in our survey were endorsed by less than half of the sample, suggesting that some potentially effective pain management strategies may be underused. Therefore, primary care physicians, primary care-mental health providers, and rehabilitation specialists can play an important role in introducing and monitoring the efficacy of a wider variety of pain self-management strategies, and discussing with patients which strategy might be most appropriate for addressing different types of pain complaints. Because exercise was both commonly endorsed and rated as effective, primary care providers might benefit from providing additional education and support to patients regarding the value of pacing (e.g., the value of rest in the context of moderated physical activity, versus a common pitfall of overexertion followed by extended bed rest). There also may be opportunities to integrate feedback on the importance of exercise with a plan to manage concerns related to personal safety and reinjury, potentially aided by referral to a supervised exercise plan with consultation from physical and occupational therapists. In addition to services provided by physical and occupational therapists, VA mental health providers located in both primary care and specialty settings may be in a position to address common anxieties pertaining to reinjury and to deliver nonpharmacological interventions for pain, such as progressive muscle relaxation, biofeedback, and diaphragmatic breathing, which were only used by a minority of the sample, or other group strategies, such as pain school or pain selfmanagement groups. Indeed, elements of such cognitivebehavioral approaches have been shown to be both effective and well received in studies of veterans with pain and PTSD MILITARY MEDICINE, Vol. 180, August 2015

5 FIGURE 2. Correlations between frequency and effectiveness of self-management strategies. Items are ordered from left to right based on frequency of endorsement in the sample. Points represent value of Spearman rank correlation coefficient; whiskers represent 95% confidence interval. Positive correlations indicate more frequent use is associated with greater effectiveness, whereas negative correlations indicate more frequent use is associated with less effectiveness. Confidence intervals which overlap a value of zero are not statistically significant. No variability in frequency of use and effectiveness was noted for Anticonvulsants (n = 5) or Corticosteroids (n = 1), thus these items were excluded from the figure. PMR = Progressive Muscle Relaxation; TENS = Transcutaneous Electrical Nerve Stimulation. Limitations in our investigation are evident and are worth mention. Primarily, our sample size was restricted, and our methods were limited to the description of self-report data that may not be generalizable to a larger population of veterans with a history of TBI. It is possible that our results may be influenced by nonresponse bias as well, based on the 22 individuals who did not return study materials. Furthermore, we were unable to conduct structured clinical interviews to establish or verify injury history or control for other chronic medical concerns. Future studies may explore the use and efficacy of pain self-management strategies in a larger, more representative sample of veterans in the postacute TBI recovery period, to include complementary and alternative medicine strategies, and examine the relative impact of mental health comorbidities on perceived efficacy. CONCLUSIONS Multiple chronic pain locations, affective disturbance, and concerns of reinjury are common in veterans with TBI history. Our results suggest that regular exercise and antidepressant use were associated with positive perceptions of pain outcomes, but other viable self-management techniques may be underused. Future studies on chronic pain trajectories, interventions for pain and comorbidities, and observation of long-term outcomes are needed. ACKNOWLEDGMENTS Research reported in this manuscript was supported by the VA Center for Integrated Healthcare pilot grant program. Preparation of this manuscript was supported by the VA Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, and the Center for Integrated Healthcare/VA Western New York Healthcare System at Buffalo. REFERENCES 1. Nampiaparampil DE: Prevalence of chronic pain after traumatic brain injury: a systematic review. JAMA 2008; 300: Walker WC: Pain pathoetiology after TBI: neural and nonneural mechanisms. J Head Trauma Rehabil 2004; 19: Uomoto JM, Esselman PC: Traumatic brain injury and chronic pain: differential types and rates by head injury severity. Arch Phys Med Rehabil 1993; 74: MILITARY MEDICINE, Vol. 180, August

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