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

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

17. Diseases, symptoms or conditions for which acupuncture has been PROVEN-through controlled trials-to be an effective treatment: Adverse reactions to radiotherapy and/or chemotherapy Allergic rhinitis (including hay fever) Biliary colic Depression (including depressive neurosis and depression following stroke) Dysentery, acute bacillary Dysmenorrhoea, primary Epigastralgia, acute (in peptic ulcer, acute and chronic gastritis, and gastrospasm) Facial pain (including craniomandibular disorders) Headache Hypertension, essential Hypotension, primary Induction of labour Knee pain Leukopenia Low back pain Malposition of fetus, correction of Morning sickness Nausea and vomiting Neck pain Pain in dentistry (including dental pain and temporomandibular dysfunction) Periarthritis of shoulder Postoperative pain Renal colic Rheumatoid arthritis Sciatica Sprain Stroke Tennis elbow WHO Acupuncture and The NIH Consensus Study

18. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which FURTHER PROOF IS NEEDED: Abdominal pain (in acute gastroenteritis or due to gastrointestinal spasm) Acne vulgaris Alcohol dependence and detoxification Bell’s palsy Bronchial asthma Cancer pain Cardiac neurosis Cholecystitis, chronic, with acute exacerbation Cholelithiasis Competition stress syndrome Craniocerebral injury, closed Diabetes mellitus, non-insulin- dependent Earache Epidemic haemorrhagic fever Epistaxis, simple (without generalized or local disease) Eye pain due to subconjunctival injection Female infertility Facial spasm Female urethral syndrome Fibromyalgia and fasciitis Gastrokinetic disturbance Gouty arthritis Hepatitis B virus carrier status Herpes zoster (human (alpha) herpesvirus 3) Hyperlipaemia Hypo-ovarianism Insomnia Labour pain Lactation, deficiency Male sexual dysfunction, non-organic Ménière disease Neuralgia, post-herpetic WHO Acupuncture and The NIH Consensus Study

19. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which FURTHER PROOF IS NEEDED: Neurodermatitis Obesity Opium, cocaine and heroin dependence Osteoarthritis Pain due to endoscopic examination Pain in thromboangiitis obliterans Polycystic ovary syndrome (Stein- Leventhal syndrome) Postextubation in children Postoperative convalescence Premenstrual syndrome Prostatitis, chronic Pruritus Radicular and pseudoradicular pain syndrome Raynaud syndrome, primary Recurrent lower urinary-tract infection Reflex sympathetic dystrophy Retention of urine, traumatic Schizophrenia Sialism, drug-induced Sjögren syndrome Sore throat (including tonsillitis) Spine pain, acute Stiff neck Temporomandibular joint dysfunction Tietze syndrome Tobacco dependence Tourette syndrome Ulcerative colitis, chronic Urolithiasis Vascular dementia Whooping cough (pertussis) WHO Acupuncture and The NIH Consensus Study

20. 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: Chloasma Choroidopathy, central serous Colour blindness Deafness Hypophrenia Neuropathic bladder in spinal cord injury Pulmonary heart disease, chronic Small airway obstruction Irritable colon syndrome

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 verde vs 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)