Traumatic brain injury (TBI) generates a broad range of disabling problems and impairment. Among the most challenging concomitants is that of pain. Because trauma to the brain is frequently accompanied by trauma to other bodily systems, it should not be surprising that pain is a clinical issue with various presentations at various stages posttrauma in a high number of survivors of TBI. Given the complexity of both central and peripheral pain generators and perpetuators, as well as predisposing and reactive psychoemotional sequelae, management of TBI with comcomitant pain is often steeped in misconceptions, myths, misdiagnosis, and mistreatment.
Appropriate management of persons with TBI clearly requires an understanding of the causes of pain in this patient population in acute as well as postacute settings and a comprehensive knowledge base regarding treatment options for the variety of pain conditions that may present in these individuals. This issues describes current state-of-the-art understanding regarding the dual diagnosis of TBI and pain.
The first article, by Drs Nicholson and Martelli, describes the “problem of pain” and gives a conceptual overview and framework for pain associated with cranial and cerebral trauma. This article reviews fundamental issues related to understanding the nature of pain, in particular chronic pain, and important distinctions between acute and chronic pain, neurobiological subtrates, the problem of mind-body dualism, and role of psychosocial factors and response bias.
Dr Walker reviews the pathophysiologic mechanisms involved in post-TBI pain disorders, examining both neurogenic and nonneurogenic contributors. Dr Ivanhoe and Hartman provide readers with an analysis of medical assessment and treatment of clinical pain disorders associated with TBI. They explore the broad spectrum of issues that may contribute to pain complaints in this patient population, as well as associated treatment methodologies. Drs Martelli, Zasler, Bender, and Nicholson then take on the task of reviewing and providing clinical caveats on the psychological, neuropsychological, and medical issues germane to the assessment and management of pain in persons with TBI. They present a biopsychosocial model for guiding assessment and treatment for the potentially widespread functional disability that accompanies chronic pain.
Wrapping up the clinical review articles for this special issue is an article addressing the integration of psychological and neuropsychological services in a multidisciplinary pain management treatment model for persons with TBI. This article is authored by Drs Branca and Lake and reviews the challenges that healthcare practitioners face in treating this set of dual diagnoses and the importance of utilizing a multidisciplinary team approach as well as adequate coordination of care across various healthcare disciplines. Lastly, a clinical research article and topic review article is presented by Dr Hecht that addresses occipital nerve blocks in post concussive headache.
It is our hope that this special issue of JHTR provides readers with a broad overview on the issues of pain assessment and management in persons with TBI. This foundation of knowledge will hopefully serve as impetus for readers in pursuing a broader clinical knowledge base and repertoire for optimizing the treatment of pain and related issues across the spectrum of TBI care.