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Pain After Pediatric Traumatic Brain Injury: Not All in the Head

February 21, 2018
Headaches are the most common symptom expected in children following a traumatic brain injury but pain arising in other regions of the body are common but less often recognized, and deserve equal attention.

With Vivian Kwan, PhD candidate, and John Kuluz, MD

Headache is a common pain complaint from children who have suffered traumatic brain injury (TBI). However, researchers and physicians who focus only on resolving the pain arising from headaches may be missing significant related TBI pain, perhaps delaying recovery,1 according to a review published in the Journal of Neurotrauma.

Keith Yeates, MD, professor and Ward Chair of Pediatric Brain Injury at the University of Calgary in Alberta, Canada, and his team, including Vivian Kwan, MSc, analyzed the literature to examine the management of non-headache pain in this pediatric population. The researchers identified 109 studies that addressed pain in children after a traumatic brain injury.1

"Eighty-seven percent of the studies were looking at headache only and no other types of pain," said Vivian Kwan, a PhD candidate in clinical neuropsychology at the University of Calgary and first author of the paper. The other 13% of selected studies reported on headache pain or overall pain and half of those were only case studies.1

After a traumatic pain injuring, pediatric patients often experience pain beyond headaches.Patients with TBI may experience pain far beyond headache, so a full body workup is warranted.

Only one study suggested that more research was needed on non-headache pain in the pediatric TBI population.2 These authors found that over half of teens (57%) with traumatic brain injury reported pain in multiple body sites, particularly the back, lower limbs, and neck.2 Despite that finding, Ms. Kwan told Practical Pain Management, “pain other than headache is often not addressed in pediatric TBI research.”

The review of any pain associated with TBI in peds ''does highlight a deficiency in the literature," said John Kuluz, MD, director of traumatic brain injury and neurorehabilitation at Nicklaus Children's Hospital in Miami, and associate professor of pediatrics at Florida International University College of Medicine in Miami.He reviewed the study for Practical Pain Management.

A Closer Look at the Methodology for a 'Scoping' Review 

The Calgary research team conducted what is known as a scoping review;1 this analysis differs from a systematic review in that is it not asking a specific question but rather is ''getting a map of what is out there in the literature."

The researchers looked for relevant research published up to October 2016. They initially found more than 1,500 papers, with the first published in 1806, but in the end, only 109 met their criteria.1

Primary outcomes criteria were pain characteristics reported in children surrounding (before and after) a traumatic brain injury.1 Any mention of a diagnosis of TBI was accepted based on internationally recognized measures, such as the World Health Organization Collaborating Center Task Force on Mild Traumatic Brain Injury.3

Among their findings and conclusions,1 after reviewing the studies were:

  • Inconsistency in pain reporting. Individual studies used a variety of ways to assess pain. Some assessed intensity by body region, other used an overall score spanning the entire body. Some ask about specific types of pain. Others used symptom checklists.
  • No consistent assessment process. Assessing pain in these research studies was problematic and a major limiting factor to comparing results.
  • Pain research needs to broaden. Since pain ''is linked to worse recovery, poorer quality of life and can be long-lasting" say Ms. Kwan and the research team, changing in the current approach to assessing pain, especially in the pediatric population is needed.

Why children with TBI get non-headache pain, is not clear, the researchers said, although a study of adults with traumatic brain injury pointed to selective damage occurring in the pain and temperature systems that may underlie the development of centralized pain in children with TBI.1 Orthopedic injuries that occurred concurrently may also play role in the experience of pain beyond the head, the authors suggested.4-6

Implications Given the Limits of Understanding on Pain Following TBI

Going forward, researchers are urged to “focus more on non-headache pain then has been studied in the past,” Ms. Kwan told Practical Pain Management, so as to improve the chances of prompt pain relief. "We know pain is related to depression, to how long it takes a child to recover after depression," she said.

The researchers found areas that might be improved in future research protocols, such as examining whether recovery times vary, investigating whether children had only headache pain or presented with other types of pain complaints or pain in body regions beyond the head. In one Dutch study,7 for example, children who had multiple pain sites also had higher pain intensity.

Information is also needed on how acute pain becomes chronic after TBI, the researchers say. Some factors predictive of longer-term pain are: catastrophizing by pediatric patients. Maternal catastrophizing has been linked with pain intensity in children.

Take Home Points for Clinicians

In addition to attending to complaints of headache, the researchers suggest clinicians who assess pain should include children questions about:

  • pain intensity
  • pain duration
  • pain location
  • impact/change in daily function

Among the tools that can be used are the Headache Diary, the Pain Diary, The Pain Questionnaire and others. Importantly, the authors recommended going beyond self-reports of pain such as introducing an observational tool such as Faces Legs Activity Cry and Consolability Scale.8   Adoption of the Pediatric Pain Interference Scale9 that assesses for the impact of pain on daily activities over the past week would also be beneficial in improving pain reporting.

Simple questioning is also advised. Ms Kwan said, "It doesn't take too much time to ask: Do you have pain in other areas of your body besides your head?''  

Expanding Expectations of Systemic Pain in Peds Experiencing TBI 

While more comprehensive research is clearly needed on non-headache following traumatic brain injury in children, Dr. Kuluz said it was understandable that the emphasis has been on headache pain. "Ninety-five percent of concussion patients experience headaches," he said, citing his own lengthy experience and research.10,11

Talking to the patient is essential, he said. "I spend a lot of time talking to my patients, getting a detailed history and especially asking what has been bothering them; where are they having pain or discomfort? We are always looking for pain, wherever it may be."

Besides headache pain, his TBI patients often complain of neck pain. "The neck pain often leads to headache," he said “yet, headache treatment is not always effective. We definitely need a more robust investigation of therapies for headache, and for head pain that may be originating in the neck or elsewhere."

We’ve also noted that some patients experience eye issues, including oculomotor dysfunction and ocular migraine, following traumatic pain injuries, Dr. Kuluz said. In effect, when presented with a child who has a history of TBI, pain practitioners will want to do a full workup for pain from head to toe.  Neither Dr. Kuluz or the study authors have any relevant disclosures

Last updated on: February 16, 2018
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Recognizing and Treating Concussions Related to Sports Injuries

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1 comment.

By akonen on 02/27/2018
TBI in children as well as adults has an often overlooked sequlae. Intracranial hypertension is frequently present and not considered. It can become persistent if not recognized by narrowing venous return from the brain. This same pressure is exerted on the spinal cord barring a non-communicating CSF flow problem. In turn, diffuse pain may present and ultimately possible autonomic and other small fiber neuropathies.
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