Michael F. Martelli

Chronic Pain and Neuropsychological Functioning

This review article examines the effect of chronic pain on neuropsychological functioning. Primary attention is given to studies that include patient groups without a history of traumatic brain injury (TBI) or neurologic disorders. Numerous studies were identified that demonstrate neuropsychological impairment in patients with chronic pain, particularly on measures assessing attentional capacity, processing speed, and psychomotor speed. Despite suggestive findings, further studies are needed to clarify the variables that mediate the impact of pain on neuropsychological functioning and the unique role of various symptoms often associated with chronic pain.

Posttraumatic Headache: Neuropsychological and Psychological Effects and Treatment Implications

Posttraumatic headache (PTHA) is a frequent occurrence following trauma to the head, brain, and/or neck. Estimates of persistence for 6 months are as high as 44%. Review of available studies examining the effect of headache on neuropsychological test findings reveals that chronic headache pain, and chronic pain generally, exerts a significant and negative effect that poses a challenge to differential diagnostic efforts in the evaluation of mild brain injury. Given that PTHA is the most common postconcussive symptom and most frequent type of posttraumatic pain associated with mild traumatic brain injury (TBI), it follows that resolution of the postconcussion syndrome, and successful posttraumatic adaptation, may frequently rely on success in coping with PTHA symptomatology. Viewing PTHA from a biopsychosocial perspective, a general outline is offered for improving both assessment and treatment of PTHA. In addition, the most promising psychology-based treatment interventions are reviewed.

Psychological, neuropsychological, and medical considerations in assessment and management of pain.

Pain is a common yet challenging problem, particularly following traumatic injuries to the head or neck. It is a complex, multidimensional subjective experience with no clear or objective measures; yet it can have a significantly disabling effect across a wide range of functions. Persisting misconceptions owing to mind-body dualism have hampered advances in its understanding and treatment. In this article, a conceptualization of pain informed by recent research and derived from a more useful biopsychosocial model guides discussion of relevant medical, psychological, and neuropsychological considerations. This pain process model explains chronicity in terms of hyperresponsiveness and dysregulation of inhibitory or excitatory pain modulation mechanisms. Related neurocognitive effects of chronic pain are examined and recommendations for minimizing its confounding effects in neuropsychological evaluations are offered. A biopsychosocial assessment model is presented to guide understanding of the myriad of factors that contribute to chronicity. A brief survey of general classes and samples of the more useful pain assessment instruments is included. Finally, this model offers a rational means of organizing and planning individually tailored pain interventions, and some of the most useful pharmacologic, physical, and behavioral strategies are reviewed.

Mild traumatic brain injury: Impairment and disability assessment caveats

Mild traumatic brain injury (MTBI) accounts for approximately 80% of all brain injuries, and persistent sequelae can impede physical, emotional, social, marital, vocational, and avocational functioning. Evaluation of impairment and disability following MTBI typically can involve such contexts as social security disability application, personal injury litigation, workers compensation claims, disability insurance policy application, other health care insurance policy coverage issues, and the determination of vocational and occupational competencies and limitations. MTBI is still poorly understood and impairment and disability assessment in MTBI can present a significant diagnostic challenge. There are currently no ideal systems for rating impairment and disability for MTBI residua. As a result, medicolegal examiners and clinicians must necessarily familiarise themselves with the variety of disability and impairment evaluation protocols and understand their limitations. The current paper reviews recommended procedures and potential obstacles and confounding issues.

Community based rehabilitation: Special issues

The primary goal in the developing field of community based rehabilitation (CBR) for individuals with TBI / ABI is community participation and integration. At present, CBR is less than clearly defined and is represented by a set of interventions with varied types, degrees of clinical support and models of intervention that are conducted for a diverse and complex set of individuals, situations, deficits and settings. Nonetheless, holistic neurorehabilitation programs should be considered both evidence based and a practice standard. This paper attempts to address some of the significant issues relevant to optimizing long term adaptation for persons receiving CBR. The article also addresses the current need for definitions, models, program classifications and comparisons, as well as programmatic methodologies by attempting to integrate some of the best scientifically supported methodologies within an eclectic holistic rehabilitation model that is easily understood and teachable to persons with TBI, families and rehabilitation professionals. This model and associated methodologies are intended to inform best practices while offering a framework for hypothesis generation, clinical decision-making, evaluation of treatment outcomes and direction of future research.

Confounding Effects of Pain, Psychoemotional Problems or Psychiatric Disorder, Premorbid Ability Structure, and Motivational or Other Factors on Neuropsychological Test Performance

Whereas neuropsychological techniques may provide sensitive and standardized measures of multiple cognitive or other functions, interpretation may be confounded by the effects of pain, psychoemotional distress or psychiatric disorder, sleep disturbance, premorbid ability structure, motivational lapses or conscious dissimulation, or other factors. Such confounding factors are common in many patient populations such as persistent PCS. Most studies have focused on one or another of these factors, although it is likely that a combination is operative in most cases. It is expected that there will be continued progress addressing these issues with further clarification of the sensitivity and specificity of neuropsychological techniques.

Chapter 32 – Neurobehavioral disorders

Neurobehavioral disorders are composed of a large group of behavioral impairments seen in association with brain disease (e.g., stroke, multiple sclerosis, dementia, and neuro-oncological conditions), transient as well as permanent brain impairments (e.g., metabolic and toxic encephalopathies), and/or injury (e.g., trauma, hypoxia, and/or ischemia). The neurorehabilitative assessment and management of such disorders is often poorly addressed in the context of overall neurological, psychiatric, and rehabilitative care. Too often, more basic, yet critical, aspects of behavioral assessment and treatment are not addressed or only superficially addressed by evaluating clinicians. Physicians often overly rely on pharmacological interventions as initial and/or sole treatment approaches rather than taking a pragmatic biopsychosocial approach that focuses on holistic disease state management. This chapter provides readers with an overview of the common behavioral impairments associated with brain dysfunction due to disease, injury, or toxicity. Details regarding the nature of impairments such as localization-related syndromes, affective disorders and personality disorders, among others are expounded. Principles of neurobehavioral assessment and treatment are examined including general guidelines for eliciting a history and physical, behavioral analysis, and functional behavioral assessment. General treatment caveats are provided including discussion of impairment and disability adaptation, and creation of positive behavioral supports. The topic of pharmacological management of neurobehavioral disorders is covered in numerous other references including Chapter 33 of this text.

Malingering: Overview and Basic Concepts

This section critically reviews issues associated with malingering, focusing on these in the context of traumatic brain injury (TBI), chronic pain, and Posttraumatic Stress Disorder (PTSD), or other psychoemotional problems such as depression that are often the subject of medicolegal proceedings. There will be very little discussion of malingering and related issues in the context of criminal or other forensic settings, although some such material will be presented given that many pertinent findings or contributions have been made in these other fields. The primary focus of this section will be on the differential diagnosis of malingering. There is an emphasis on TBI and chronic pain, reflecting the interests of the authors but, also, as there has been more research conducted in these areas than in PTSD, depression, or other psychoemotional problems. There is notably considerable overlap in the chapters of this section, which reflects both the commonality of issues, for example, the comorbidity between the disorders of interest or the use of multiscale self-report inventories to assess malingering, exaggeration, or other accentuation of symptomatology in all of the clinical conditions that are a focus of the chapter.

Sodium amobarbital: historical perspectives and neurorehabilitation clinical caveats.

The sodium amobarbital (amytal) (SA) interview is a technique that has been utilized in the treatment of a variety of disorders since its introduction in 1929. Since that time, there has been an assortment of research conducted showing its value in both differential diagnosis and treatment of multiple conditions. Notwithstanding the substantive amount of experience with the technique and its application to a myriad number of clinical conditions, it remains a seldom used procedure in clinical practice and certainly in neurorehabilitation. This paper will review the history of SA, as well as summarize the literature published over the past two decades on the clinical applications of SA to provide readers with a foundation for the utility of this agent, as well as the sodium amytal interview (SAI) in neurorehabilitation clinical practice. Special emphasis will be placed on the use of the SAI in individuals with functional disorders that may be seen in the neurorehabilitation setting, as well as various classes of pain disorders.

The Effect of Compensation Status

As discussed in Chapter 14, there had been increased concern about the possibility of malingering or related behaviors following the advent of various compensation plans from the mid-late 1800s. The relationship between compensation status, that is, whether the person is receiving compensation benefits or has the prospects of receiving compensation, and various aspects of response to injury or disability, has subsequently been extensively investigated. Of note, there are many different possible methods for procuring compensation with different types of injuries or disabilities in different jurisdictions, for example, various worker’s compensation, Social Security, and disability schemes, automobile insurance involving either tort liability or no-fault compensation, various private insurance plans, the U.S. Veterans Administration, and others.