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Chronic pain, including chronic low back pain, is common among individuals with a history of traumatic brain injury (TBI). The good news is that many treatments for chronic low back pain are safe and effective for individuals with TBI. This clinical pocket card summarizes current evidence-based approaches to treating chronic low back pain,
Treatments for chronic low back pain fall into 2 broad categories: pharmacologic (ie, medication) and nonpharmacologic.
Considerations for pharmacologic chronic pain treatments for individuals with TBI
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Chronic use (particularly daily) of nonsteroidal anti-inflammatory drugs or acetaminophen, either alone or combined with caffeine, may lead to medication overuse or rebound headaches. Treatment of medication overuse headaches requires patients to stop daily use of acute headache medication.
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Patients with a history of TBI can be more sensitive to side effects. Watch closely for toxicity and drug-drug interactions. Assess regularly for side effects.
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Unless side effects prevail, give full therapeutic trials at maximal tolerated doses before discontinuing a medication trial. Under-treatment is common.
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Educate patients and family/caregivers to avoid the use of alcohol with the medications.
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When possible, avoid medications that lower the seizure threshold (eg, bupropion, tramadol, bronchodilators, tricyclics, opiates/narcotics).
Adverse events associated with flumazenil treatment for the management of suspected benzodiazepine intoxication–a systematic review with meta-analyses of randomised trials.
When possible, avoid medications that can cause cognitive dysfunction or exacerbate confusion (ie, anticholinergic agents, narcotics, lithium, benzodiazepines, topiramate).
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Suicidal ideation is higher in the TBI population compared with the general population. Individuals prescribed the following medications should be monitored regularly for suicidality: tricyclics (ie, amitriptyline, desipramine, doxepin, nortriptyline), mirtazapine, and trazadone.
Considerations for nonpharmacologic chronic pain treatments for individuals with TBI
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Nonpharmacologic interventions for low back pain include physical therapy, acupuncture, spinal manipulation, prescribed exercise, and cognitive behavior therapies such as cognitive restructuring, mindfulness, and relaxation techniques. Most nonpharmacologic treatments require involvement by the patient. The following are common cognitive deficits and suggested cognitive adaptations that should be made for individuals with TBI to enhance therapeutic engagement.
Reduce potential distractions by muting phones and holding treatment sessions away from windows or open doorways.
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Use shorter, more frequent sessions.
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Plan breaks during sessions.
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Communication deficits:
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Use clear, structured questions and direct commands.
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Incorporate visual resources and/or gestures.
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Emphasize behavioral techniques.
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Memory deficits:
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Encourage the patient to use a therapy notebook or device to record information.
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Repeat salient points frequently.
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Involve a family member or caregiver.
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Executive functioning:
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Present information slowly to allow for slower processing speed.
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Focus on concrete examples during discussion. Use examples to help the patient generate possible solutions. If the patient is unable, the clinician should suggest solutions and confirm understanding with the patient.
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Use a “say it, show it, do it” approach to model tasks for the patient for tasks to be completed in session as well as to confirm understanding of homework assignments (eg, prescribed exercises).
Please see the treatment algorithm graphic (fig 1).
This page was developed by Alison M. Cogan, PhD, OTR/L (e-mail address:[email protected]); Marc A. Silva, PhD; and Diana P. Brostow, PhD, MPH, RDN.
Disclaimer
This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital. The views expressed within are those of the author(s) and do not necessarily represent the official policy or position of the Department of Veterans Affairs or other U.S. Government agency. This information is not meant to replace the advice of a medical professional and should not be interpreted as a clinical practice guideline. This Information/Education Page may be reproduced for noncommercial use for health care professionals and other service providers to share with their patients or clients. Any other reproduction is subject to approval by the publisher.
Acknowledgment
Graphic adapted from the VA/DoD Clinical Practice Guideline (CPG) for Low Back Pain.
References
Department of Veterans Affairs, Department of Defense
VA/DoD Clinical Practice Guidelines: diagnosis and treatment of low back pain (LBP.
Adverse events associated with flumazenil treatment for the management of suspected benzodiazepine intoxication–a systematic review with meta-analyses of randomised trials.
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