Posttraumatic Pain Disorders: Medical Assessment and Management

Zasler, Nathan D.; Martelli, Michael F.; Nicholson, Keith; Horn, Lawrence J.

doi:10.1891/9780826143051.0058

Cited by 5 publications

(7 citation statements)

References 100 publications

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“…The mean disease progression here was 4 months, with a mean of 5.24 months. Patients in the chronic stage were more likely to have spasticity, ossification, and the other causes mentioned above ( Barr et al, 2013 ; Thibaut et al, 2015 ; Zasler et al, 2021 , 2022 ), which may partly explain why they performed worse with physiotherapy than in previous studies ( Bonin et al, 2022 ). This could also be related to limb range of motion, frequency of physiotherapy, and other therapy related factors.…”

Section: Discussionmentioning

confidence: 90%

“…From previous studies, increased spasticity and autonomic nerve activity may occur in patients with brain injury ( Kyle and McNeil, 2014 ; Bartolo et al, 2016 ). The following causes of pain may be common in DOC patients ( Barr et al, 2013 ; Zasler et al, 2021 , 2022 ): spasticity ( Thibaut et al, 2015 ), ossification, dystonia, rigidity, contractures, musculoskeletal pain, neuropathic pain, shoulder subluxation, scoliosis, complex regional pain syndrome, and/or pressure ulcers, which are more likely to cause potential pain during care and mobilization. According to a previous case report on pain management ( Lanzillo et al, 2016 ), relieving the pain of DOC patients with spasticity may improve the diagnosis of the patient’s consciousness.…”

Section: Introductionmentioning

confidence: 99%

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Pain assessment during physiotherapy and noxious stimuli in patients with disorders of consciousness: A preliminary study

Shen

Tang

Yan

et al. 2022

Front. Integr. Neurosci.

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ObjectivesThe primary purpose of this study is to determine whether patients with disorders of consciousness (DOC) (unresponsive wakefulness syndrome, UWS; minimally conscious state, MCS) experience pain during physiotherapy and noxious stimuli in a larger patient population.Materials and methodsThe patients’ level of consciousness was measured with the Coma Recovery Scale-Revised (CRS-R). Additionally, the Nociception Coma Scale-revised (NCS-R) was used to assess their pain response. The NCS-R total scores between UWS and MCS at baseline, physiotherapy and noxious stimulus were compared using the Mann-Whitney U test (Wilcoxon rank-sum test) and the Kruskal-Wallis H test with Bonferroni correction.ResultsThe study enrolled 93 participants. There was a statistically significant difference in NCS-R total scores between the three conditions (H = 215.25, p < 0.001). At baseline, there was no statistically significant difference between MCS and UWS (U = 378, z = –1.35, p = 0.178). While there was a statistically significant difference between MCS and UWS during physiotherapy (U = 1,362, z = –3.06, p < 0.01) and under noxious stimuli (U = 5142.5, z = –11.22, p < 0.001).ConclusionPhysiotherapy improved the activity responsiveness of DOC patients, and patients experienced less potential pain. However, some DOC patients, especially MCS patients, perceived pain under the noxious stimuli.

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Section: Discussionmentioning

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Pain assessment during physiotherapy and noxious stimuli in patients with disorders of consciousness: A preliminary study

Shen

Tang

Yan

et al. 2022

Front. Integr. Neurosci.

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“…Pain assessment and management in patients with DoC is both challenging and require major attention (Zasler, Martelli, et al, 2022). Pain refers to an "unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage" (Raja et al, 2020).…”

Section: Pain Assessment and Managementmentioning

confidence: 99%

Neuro-orthopaedic assessment and management in patients with prolonged disorders of consciousness: A review

Thibaut,

Aloisi,

Dreessen

et al. 2024

NRE

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BACKGROUND: Following a severe acquired brain injury, neuro-orthopaedic disorders are commonplace. While these disorders can impact patients’ functional recovery and quality of life, little is known regarding the assessment, management and treatment of neuro-orthopaedic disorders in patients with disorders of consciousness (DoC). OBJECTIVE: To describe neuro-orthopaedic disorders in the context of DoC and provide insights on their management and treatment. METHODS: A review of the literature was conducted focusing on neuro-orthopaedic disorders in patients with prolonged DoC. RESULTS: Few studies have investigated the prevalence of spastic paresis in patients with prolonged DoC, which is extremely high, as well as its correlation with pain. Pilot studies exploring the effects of pharmacological treatments and physical therapy show encouraging results yet have limited efficacy. Other neuro-orthopaedic disorders, such as heterotopic ossification, are still poorly investigated. CONCLUSION: The literature of neuro-orthopaedic disorders in patients with prolonged DoC remains scarce, mainly focusing on spastic paresis. We recommend treating neuro-orthopaedic disorders in their early phase to prevent complications such as pain and improve patients’ recovery. Additionally, this approach could enhance patients’ ability to behaviourally demonstrate signs of consciousness, especially in the context of covert awareness.

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“…Pain should be understood as defined by the International Association for the Study of Pain to be "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" (Raja, Carr, Cohen, et al, 2020). Clinicians should understand distinctions between nociceptive and neuropathic pain when providing testimony in a medicolegal case involving a patient with DoC (Zasler, Martelli, Clanton, 2022).…”

Section: Medicolegal Aspects Of Pain and Sufferingmentioning

confidence: 99%

“…Additionally, if the individual is deemed capable of perceiving pain and suffering that appropriate decision-making regarding care has been applied as this may have implications on legal liability as well as potential negligence claims for healthcare providers if otherwise mismanaged. Treatment rendered for pain and suffering must weigh benefits and risks of same in the context of ethical principles of beneficence and non-maleficence which can be particularly complex in such situations (Bodien, Katz, Schiff, et al, 2022;Zasler, Martelli, Clanton, 2022).…”

Section: Medicolegal Aspects Of Pain and Sufferingmentioning

confidence: 99%

Medicolegal issues and disorders of consciousness

Zasler

2024

NRE

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BACKGROUND: The tasks and responsibilities that come with clinician involvement in medicolegal proceedings can be daunting and particularly so in challenging areas such as provision of medicolegal opinions in cases involving disorders of consciousness (DoC). OBJECTIVE: The aim of this narrative review was to provide education and advice to healthcare practitioners who by choice or circumstance are asked and/or required to provide medicolegal opinions in cases involving patients with DoC. METHODS: A literature search was conducted using PubMed Central and MedlinePlus for articles dealing with clinician involvement in medicolegal cases involving persons with DoC. The information provided also integrates the authors nearly 40 years of clinical experience and brain injury medicine practice and “trials and tribulations” associated with medicolegal involvement in such cases. RESULTS: The literature was found to be replete with articles on brain death and withdrawal/withholding of care (which are not the focus of this review). The extant medical literature in brain injury medicine on the other hand is currently lacking in practical information for clinicians working “in the trenches” regarding the challenges and caveats of medicoegal involvement in such cases. CONCLUSION: This review provides the reader with a big picture overview of the most pertinent medicolegal topics inherent in clinical work with patients with DOC including pertinent nomenclature, caveats regarding forensic consultation including independent medical examinations, testimony tips, discussion of life expectancy/median survival concepts, prognostication in a medicolegal context, documentation and record keeping as well as some of the specific challenges pertinent to these types of brain injury cases that are not per se relevant in less severe injuries.

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Posttraumatic Pain Disorders: Medical Assessment and Management

Cited by 5 publications

References 100 publications

Pain assessment during physiotherapy and noxious stimuli in patients with disorders of consciousness: A preliminary study

Pain assessment during physiotherapy and noxious stimuli in patients with disorders of consciousness: A preliminary study

Neuro-orthopaedic assessment and management in patients with prolonged disorders of consciousness: A review

Medicolegal issues and disorders of consciousness

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