Persistent Pain in Adolescents Following Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of pediatric disability. Although persistent pain has been recognized as a significant postinjury complication, there is a paucity of data concerning the postinjury pain experience of youth. This study aimed to examine the prevalence of persistent pain in adolescents after TBI, identify risk factors for pain, and evaluate the impact of pain on adolescent health-related quality of life. Participants included 144 adolescents with mild to severe TBI who were followed over 36 months after injury. At 3-, 12-, 24-, and 36-month assessments, measures of pain intensity, depression, posttraumatic stress disorder, and health-related quality of life were completed by adolescents. Findings demonstrated that 24.3% of adolescents reported persistent pain (defined as usual pain intensity ≥3/10) at all assessment points after TBI. Female sex (odds ratio = 2.73, 95% confidence interval = 1.12–6.63) and higher levels of depressive symptoms at 3 months after injury (odds ratio = 1.26, 95% confidence interval = 1.12–1.43) were predictors of persistent pain at 36 months. Furthermore, mixed linear models indicated that early pain experience at 3 months following TBI was associated with a significantly poorer long-term health-related quality of life.     

Behavioral and Physiologic Indicators of Pain in Nonverbal Patients with a Traumatic Brain Injury: An Integrative Review

The use of behavioral and physiologic indicators is recommended for pain assessment in nonverbal patients. Traumatic brain injuries (TBI) can lead to neurologic changes and affect the way patients respond to pain. As such, commonly used indicators of pain may not apply to TBI patients. This study aimed to review the literature about behavioral/physiologic indicators of pain in nonverbal TBI patients. An integrative review method was used. Medline (from 1948 to June 2011), Cinahl, and Cochrane databases were searched using any combination of the terms brain injury, behavioral indicators, behavioral scale, physiologic indicators, pain, pain assessment, and pain measurement. All articles reporting expert opinion or original data about the validity of behavioral and/or physiologic indicators of pain in TBI patients were considered. For each article included, the quality of findings/clinical recommendations was graded independently by two raters using SORT taxonomy. Eight papers were reviewed. Overall, TBI patients seemed to present a wider range of behavioral reactions to pain than other adult populations. In addition to the commonly observed grimace, agitation, and increased muscle tension, 14%-72% of TBI patients showed raising eyebrows, opening eyes, weeping eyes, and absence of muscle tension when exposed to pain. Those atypical reactions appeared to be present only in the acute phase of TBIs recovery. Similarly to other populations, vital signs were identified as potential indicators of pain in TBI patients. Further research studying TBI patients and considering changes in level of consciousness, location/severity of brain injury, and administration of analgesic/sedative is needed. Until then, nurses should follow the current clinical recommendations.     

The Psychometric Properties of the FLACC Scale Used to Assess Procedural Pain

The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is one of the most commonly and widely used behavioral observation pain scales. The aim of this study was to test the psychometric and practical properties of the FLACC scale to quantify procedural pain in infants and young children. Twenty-six clinicians independently applied the FLACC scale to segments of video collected from 100 children aged 6 to 42 months undergoing a procedure. Video segments were scored by 4 reviewers. Inter- and intrarater reliability coefficients were high (.92 and .87, respectively). Linear mixed modeling confirmed scale responsiveness (differences in difference between FLACC scores across phases for painful versus nonpainful procedures was 4.2, 95% confidence interval = 3.67-4.81). Sensitivity and specificity were 94.9% and 73.5%, respectively, at a cutoff of 2. However, the mean difference across phases for children with baseline scores >3 was much lower than for children with scores <3, P?=?.0001. Correlations between FLACC and Visual Analog Scale observer pain and distress were good (r?=?.74 and r?=?.89, respectively). This study supports the reliability and sensitivity of the FLACC scale for procedural pain assessment. However, the circumstances of procedures interfered with application of the scale and the findings question the capacity of the scale to differentiate between pain- and nonpain-related distress.

Comorbidity of Pain and Depression Among Persons With Traumatic Brain Injury

Objective

To assess the prevalence of pain, depression, and comorbid pain and depression among a civilian sample of persons with traumatic brain injury (TBI).

Design

Longitudinal survey design with 1-year follow-up.

Setting

Inpatient rehabilitation and the community.

Participants

Participants (N=158) admitted to inpatient rehabilitation after moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measures

Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); pain was assessed with a numerical rating scale from 0 (no pain) to 10 (worst pain). Participants who reported average pain ≥4 were classified as having pain, and participants with PHQ-9 scores ≥10 were classified as depressed.

Results

Both pain and depression were more prevalent at baseline assessment (pain: 70%; depression: 31%) than at year 1 (pain: 34%; depression: 22%). Comorbid pain and depression declined from 27% at baseline to 18% at year 1. Pain was significantly associated with depression at baseline (relative risk: 2.62, P=.003) and at year 1 (relative risk: 7.98, P<.001).

Conclusions

Pain and depression are common and frequently co-occur in persons with TBI. Although their frequency declined over the first year after injury, the strength of their association increased. Assessment and treatment of both conditions simultaneously may lead to improved outcomes, both early after TBI and over time.     

Utilization of Behavioral Therapy Services Long-Term After Traumatic Brain Injury in Young Children

Objective

To examine associations of clinical need, defined by elevated parent ratings of child behavior problems and utilization of behavioral health services in young children with traumatic brain injury (TBI) and an orthopedic injury (OI) comparison group.

Design

Parents completed outcome measures 18 months after injury and at an extended follow-up conducted an average of 38 months postinjury.

Setting

Children's hospitals and a general hospital.

Participants

Participants included parents of 3 groups of children injured between 3 and 7 years of age (N=139): 47 children with complicated mild to moderate TBI, 18 with severe TBI, and 74 with OI.

Interventions

Not applicable.

Main Outcome Measures

Parents completed ratings of child behavior, mental health symptomology, and family functioning at both visits; at the extended follow-up, they reported utilization of behavior therapy or counseling services since the 18-month follow-up visit.

Results

Children with TBI had more behavior problems than those with OI. Although clinical need at both follow-ups was associated with greater service utilization at the extended follow-up, all groups had unmet needs as defined by a clinical need in the absence of services. Lower socioeconomic status was associated with higher rates of unmet need across groups.

Conclusions

The results document unmet long-term behavioral health needs after both TBI and OI in children and underscore the importance of monitoring and treatment of postinjury behavior problems.     

Prior History of Traumatic Brain Injury Among Persons in the Traumatic Brain Injury Model Systems National Database

Objective

To determine the association between demographic, psychosocial, and injury-related characteristics and traumatic brain injury (TBI) occurring prior to a moderate or severe TBI requiring rehabilitation.

Design

Secondary data analysis.

Setting

TBI Model System inpatient rehabilitation facilities.

Participants

Persons (N=4464) 1, 2, 5, 10, 15, or 20 years after TBI resulting in participation in the TBI Model System National Database.

Interventions

Not applicable.

Main Outcome Measures

History of TBI prior to the TBI Model System Index injury, pre-Index injury demographic and behavioral characteristics, Index injury characteristics, post-Index injury behavioral health and global outcome.

Results

Twenty percent of the cohort experienced TBIs preceding the TBI Model System Index injury—80% of these were mild and 40% occurred before age 16. Pre- and post-Index injury behavioral issues, especially substance abuse, were highly associated with having had a prior TBI. Greater severity of the pre-Index injury as well as occurrence before age 6 often showed stronger associations. Unexpectedly, pre-Index TBI was associated with less severe Index injuries and better functioning on admission and discharge from rehabilitation.

Conclusions

Findings suggest that earlier life TBI may have important implications for rehabilitation after subsequent TBI, especially for anticipating behavioral health issues in the chronic stage of recovery. Results provide additional evidence for the potential consequences of early life TBI, even if mild.