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Conservative management of pain after TBI

Conservative management of pain after TBI. Rachel Heberling , MD Cincinnati VA Medical Center University of Cincinnati. Why Conservative Pain Management in TBI?. Increased sensitivity to medications Increased difficulty managing medications, especially prn’s

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Conservative management of pain after TBI

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  1. Conservative management of pain after TBI Rachel Heberling, MD Cincinnati VA Medical Center University of Cincinnati

  2. Why Conservative Pain Management in TBI? • Increased sensitivity to medications • Increased difficulty managing medications, especially prn’s • Increased self-efficacy via self-management • Potentially decreased number of office visits • Cost-effective

  3. Heat • Superficial heat: heating pad, hot shower, hot bath • Deep heat: ultrasound • Effective for pain relief, increased muscle flexibility • Not much evidence, but obviously effective briefly

  4. Cold • Superficial: Ice packs • Deep: cold laser • Cold effective for pain relief and reducing inflammation, but contracts muscles • Unclear mechanism and efficacy of cold laser

  5. STRETCHING! • Muscle has viscoelastic properties • Slow, deep stretch paired with deep breathing necessary • Muscle properties change for ~10 hrs after deep stretch • Evidence not compelling, but pain-relief effect of stretching is very obvious clinically

  6. Stretching!

  7. Other types of Exercise • Aerobic exercise – has huge role in decreasing muscle tension and consequent pain. • Strength training – some role in decreasing pain (e.g. core strengthening), but generally minimized until pain beginning to improve.

  8. Meditation • Increasing base of evidence for the pain relief effects of meditation • Decreases stress • Improved emotional acceptance of pain

  9. Yoga • EXCELLENT choice for exercise maintenance • Has role in decreasing active pain issues as well. • Must start in beginner class!

  10. Advanced Yoga Class

  11. Tai Chi • Becoming more popular topic of research • Have found that Tai Chi practice decreases falls in the elderly • Somewhat similar to yoga, but more focused on gentle fluid movement, as opposed to deep prolonged stretch

  12. Physical Therapy • Many treatment modalities available • Stretching • Strengthening • Ultrasound • TENS • Traction

  13. Bracing & Assistive Devices • Lumbar support • Knee braces • Cane • Walker

  14. Acupuncture

  15. Acupuncture

  16. Classified disease processes according to evidence for acupuncture efficacy 2003 Proven Needs further research Worth trying WHO, NIH Consensus Study

  17. Adverse reactions to radiotherapy and/or chemotherapyAllergic rhinitis (including hay fever)Biliary colicDepression (including depressive neurosis and depression following stroke)Dysentery, acute bacillaryDysmenorrhoea, primaryEpigastralgia, acute (in peptic ulcer, acute and chronic gastritis, and gastrospasm)Facial pain (including craniomandibular disorders)HeadacheHypertension, essentialHypotension, primary Induction of labourKnee painLeukopeniaLow back painMalposition of fetus, correction ofMorning sicknessNausea and vomitingNeck painPain in dentistry (including dental pain and temporomandibular dysfunction)Periarthritis of shoulderPostoperative painRenal colicRheumatoid arthritisSciaticaSprainStrokeTennis elbow Diseases, symptoms or conditions for which acupuncture has been PROVEN-through controlled trials-to be an effective treatment: WHO Acupuncture and The NIH Consensus Study

  18. Abdominal pain (in acute gastroenteritis or due to gastrointestinal spasm)Acne vulgarisAlcohol dependence and detoxificationBell’s palsyBronchial asthmaCancer painCardiac neurosisCholecystitis, chronic, with acute exacerbationCholelithiasisCompetition stress syndromeCraniocerebral injury, closedDiabetes mellitus, non-insulin-dependentEaracheEpidemic haemorrhagic feverEpistaxis, simple (without generalized or local disease) Eye pain due to subconjunctival injectionFemale 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 Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which FURTHER PROOF IS NEEDED: WHO Acupuncture and The NIH Consensus Study

  19. NeurodermatitisObesityOpium, cocaine and heroin dependenceOsteoarthritisPain due to endoscopic examinationPain in thromboangiitis obliteransPolycystic ovary syndrome (Stein-Leventhal syndrome)Postextubation in childrenPostoperative convalescencePremenstrual syndromeProstatitis, chronicPruritusRadicular and pseudoradicular pain syndromeRaynaud syndrome, primary Recurrent lower urinary-tract infectionReflex sympathetic dystrophyRetention of urine, traumaticSchizophreniaSialism, drug-inducedSjögren syndromeSore throat (including tonsillitis)Spine pain, acuteStiff neckTemporomandibular joint dysfunctionTietze syndromeTobacco dependenceTourette syndromeUlcerative colitis, chronicUrolithiasisVascular dementiaWhooping cough (pertussis) Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which FURTHER PROOF IS NEEDED: WHO Acupuncture and The NIH Consensus Study

  20. Chloasma Choroidopathy, central serous Colour blindness Deafness Hypophrenia Neuropathic bladder in spinal cord injury Pulmonary heart disease, chronic Small airway obstruction Irritable colon syndrome Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is WORTH TRYING because treatment by conventional and other therapies is difficult:

  21. 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 verdevs sham vs conventional guideline-based treatment • Semi-standardized verde acupuncture treatment protocol

  22. GERAC – Design • 10 sessions over 10 weeks regardless of group • 5 additional sessions for partial responders (>10%, <50% improvement) • Limited communication with acupuncturist to avoid unblinding • Allowed NSAID for rescue, max twice weekly.

  23. GERAC - Results Table 4. Primary Outcome: Pairwise Comparison of Treatment Response 6 Months After Randomization Treatment Response Intergroup Difference P Value Group 1 vs group 3 47.6 (42.4 to 52.6) vs 20.2 (13.4 to 26.7) 0.001 27.4 (23.0 to 32.1) Group 2 vs group 3 44.2 (39.2 to 49.3) vs 16.8 (10.1 to 23.4) 0.001 27.4 (23.0 to 32.1) Group 1 vs group 2 3.4 (−3.7 to 10.3) 0.39 47.6 (42.4 to 52.6) vs 44.2 (39.2 to 49.3)

  24. 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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