Settings of pain

There are several sites during the course of treatment where pain is more commonly recognized. The first is the ICU. The body in the coma or near-coma state can only respond in a limited number of ways. Most of the presentations are autonomic or reflexic, and the examiner needs to have a certain degree of awareness of the conditions to treat the individual effectively.

The obvious presentations involve the most superficial causes, that is, inflammation owing to restraints, shearing, wounds, iatrogenic lines, and tubes. The patient’s responses are frequently to fight the respirator, pull at the lines, and fidget. A careful inspection of the skin is required. Any increase in the individual’s spasticity should alert the team that (possibly) aberrant, afferent, in-bounding messages are being sent. Any changes in the patient’s physical status can result in behavioral problems. Early stasis pneumonia (atelectasis), peptic ulcer disease (not tolerating the gastrostomy tube feedings), or changes in the patient’s urinary pH (above 7.0, increasing the risk of urea-splitting bacteria ) are some examples how subtle physical changes occurring in the ICU can lead to abnormal afferent stimulation and behavioral changes. Unfortunately, persons unfamiliar with early TBI behaviors can sometimes respond to these behaviors with sedating medications, which minimize outward signs and symptoms. The sedation can also “cover” other problems, such as changes in intracranial pressure or space-occupying lesions (while off intracranial monitoring) or a thalamic syndrome. The former is suggested by changes in the neurologic examination (the mental status evaluation, behavior, or focal signs) and requires a follow-up CT or MRI. The latter has been more easily recognized when the patient later awakens and complains .

Thalamic syndrome is appreciated mostly after strokes, when the patient usually describes burning or other dysesthesias on the contralateral face, arm, and leg (virtually unique symptoms in a neurologic differential diagnosis). In the low-level or comatose patient, the patient can manifest the syndrome with changes in blood pressure, heart rate, or restlessness. The patient will resist lying on the contralateral side and, when switched to the side of the lesion, may quickly quiet down. A survey of the injuries on CT or MRI may reveal the thalamic injury.

A trial of amitriptyline, gabapentin, desipramine, or even valproic acid can result in a significant diminution of symptoms. As always, the lower the dose prescribed the better. Starting at 25 mg of amitriptyline and increasing the dose every night by 25 mg until the desired result is obtained (sleeping soundly and awake and functional during the day) is recommended. Also, when prescribing medicine, one should try to use one medicine that can be useful for multiple problems. Although it is an anti-cholinergic and dismissed by some practitioners, amitriptyline can assist with sleep, pain, musculoskeletal conditions, and agitation . Like all medicines written for individuals with brain injury, it needs to be re-evaluated on a regular basis. Although most of these medicines are thought to affect primarily one neurotransmitter receptor, many of the medicines may actually affect several simultaneously .

In the ICU, other causes of pain or behavioral problems include subclinical seizures (electrographic events that require an electroencephalogram to demonstrate) and sleep deprivation. Although a “pain threshold” is difficult to prove objectively, empirically, one’s lack of consistent sleep is thought to lower one’s pain tolerance. The so-called “ICU syndrome” may be due in large part to sleep deprivation. It is well known that pain is associated with sleep fragmentation , but the reverse may also be true that lack of sleep promotes pain intolerance .

The second site where pain is commonly recognized is in the acute and post acute settings. Patients are actively involved with multiple therapies, and overaggressive stretching or ranging can result in various sprains and strains. Again, the manifestation of these conditions may be behavioral changes or increased spasticity. In the acute setting, as many as 11% of unrecognized fractures have been reported in the rehabilitation units . Admission total body bone scans are a simple technique to survey for possible fractures and provide baseline information for heterotopic ossification. The scan can identify possible sites of heterotopic ossification 4 to 6 weeks before changes in plain films . The integumentary system should be regularly inspected and the possibility of deep venous thromboses considered. Patients at this stage of their recovery may or may not be able to describe their problem. It is not unusual for therapists or nurses to notice a new limitation of range or warmth in the affected areas. Doppler scans, pulse oximetry, VQ scans, or spiral CT are the preferred diagnostic tools.

Lastly, as spasticity builds (even with proper treatment), nerve entrapments and contractures can occur. Although local blocks (phenol, alcohol, botulinum toxin) are encouraged and medicines can be used (baclofen, tizanidine, dantrolene, clonidine) , a definitive understanding of the extent of spasticity versus a contracture is required. If only functional range is intended or passive movement is complete, no further work-up is necessary. Electromyographic studies can be helpful but sometimes do not provide a full picture of the correct range of motion. Recommended are diagnostic blocks (ie, axillary blocks for upper extremity tightness, lumbar subarachnoid blocks for both lower extremities simultaneously) to completely paralyze the area for 1 to 2 hours and accurately confirm the range or degree of limitation. This aggressive approach to blocking the final common pathway of the nerve provides the most complete measurements. It saves time and helps decide on medical or surgical interventions. Appropriate serial casting, bracing, injections, medicines, surgical manipulations, or tendon transfers are ordered as needed.

Commonly recognized beginning in the acute rehabilitation and post acute settings are headaches, musculoskeletal conditions, and the beginning of secondary biomechanical problems.

In the last stage or community re-entry phase, job-related problems can include balance and vestibular complications (leading to falls and other accidents), environmental stressors (with its many manifestations), and secondary biomechanical complications.

Causes of pain

When evaluating any condition, a wide differential diagnosis should be considered. The assessment should not start out being system or location dependent but rather cover all major categories of disease. The categories include trauma, vascular, degenerative, congenital, metabolic, infectious, psychiatric, iatrogenic, dysimmune, and neoplastic conditions. Within these categories, the majority of all diagnoses can be made. After this categorization, organ-specific diagnoses can be made, that is, conditions affecting the neurologic or musculoskeletal systems.

The first category, trauma, includes fractures, lacerations, sprains, strains, hematomas, contusions, and ligamental, tendon, muscle, bursa, and joint injury. In addition, direct injuries to peripheral nerves , skin, viscera, and bone need to be considered.

Vascular injuries involve sites anywhere in the body, including structures in the neck , scalp, compartmental sites in the extremities, and viscera. Posttraumatic subarachnoid hemorrhages (aneurysmal) are not common and rarer still are traumatic dural sinus thromboses . Deep venous thromboses and vascular insufficiency syndromes can all lead to pain.

Degenerative changes involve those primarily of the neck and back that existed before the injury. Diskogenic, facet, and structural concerns can be exacerbated or initiated after trauma.

Congenital problems are mentioned as part of the differential diagnosis, although they have a minor role unless a pre-existing problem is involved. This involvement is noted in the pediatric types of brain injury and those with structural problems.

Metabolic conditions are important, mostly as contributors to other conditions. Hyper- and hypothyroid conditions (seen after severe TBI) contribute to neuropathy. Renal, hepatic, magnesium, and calcium alterations can lead to seizures (manifesting as headaches, behavioral conditions, confusion) or cognitive problems. Gastrointestinal (constipation) and genitourinary (urinary retention) systems can be involved with patient discomfort.

Infectious sites are primarily the lungs and bladder, but any surgical area can involve superficial or deep tissue problems with regional sites involved. Areas of particular importance are the sites of extracranial ventricular drains, ventricular-peritoneal drains (intracranially and intra-abdominally), intracranial monitors, intravenous and intra-arterial sites, all drainage tubes, and suture lines. Abrasions, fractures, and injured joints should be assessed. Meningitis, encephalitis, abscesses, diskitis, and sinusitis can all occur after TBI and require careful consideration.

Iatrogenic sources cause more metabolic and behavioral conditions than actual pain. This category includes treating with multiple medicines, especially from similar categories simultaneously. A “medication overuse headache” has also been coined .

Psychiatric causes need to be considered at all times, more commonly in the post acute settings. Because it is subjective, pain is always being questioned, especially in the chronic phase (usually defined after 6 months of continuous symptoms). The effects of posttraumatic stress, anxiety, and depression on pain have been explored by many researchers , as have the effects of motivation. Many psychologic and neuropsychologic tests are available to assist in this difficult assessment .

Painful dysimmune conditions exist primarily as vasculopathies, mononeuropathies, and mononeuritis multiplex as part of prior medical conditions. Exacerbations or initial presentation of certain potentially painful dysimmune problems (multiple sclerosis) after TBI have been debated without final resolution .

Neoplastic conditions need only be considered if trauma has occurred in the patient with a pre-existing condition. The need to appreciate two co-existing problems should not detract from an aggressive work-up of the cause of pain.

Neurologic conditions that can lead to pain include migraines, hydrocephalus, subdural hematomas, subdural hygromas, epidural hematomas, pneumocephalus, raised intracranial pressure, cerebrospinal fluid leakage with infection, seizures, cranial and spinal nerve involvement, meningeal irritation or infection, cerebral artery inflammation, lesser and greater occipital nerve bruising , supraorbital and supratrochlear nerve injury (ophthalmic division of the trigeminal nerve), radiculopathy, plexopathy, neuropathy, and complex regional pain syndrome. The trigeminal nerve innervates the sinuses, connects with the upper cervical spinal nerves (perhaps as far down as C3), and is considered one of the prime generators of migraines. Sinus clouding on radiographs after TBI is frequent but never singularly studied as a painful condition after trauma.

Musculoskeletal conditions involve structures of the neck (cervicogenic syndromes) that can involve the facets, foraminal tightness, disks, muscles, and ligaments , biomechanical aberrations at all locations of the vertebral column, tension headaches , tendonitis, adhesive capsulitis, myofascial syndromes , and temporomandibular joint (TMJ) syndrome.

Causes of pain

When evaluating any condition, a wide differential diagnosis should be considered. The assessment should not start out being system or location dependent but rather cover all major categories of disease. The categories include trauma, vascular, degenerative, congenital, metabolic, infectious, psychiatric, iatrogenic, dysimmune, and neoplastic conditions. Within these categories, the majority of all diagnoses can be made. After this categorization, organ-specific diagnoses can be made, that is, conditions affecting the neurologic or musculoskeletal systems.

The first category, trauma, includes fractures, lacerations, sprains, strains, hematomas, contusions, and ligamental, tendon, muscle, bursa, and joint injury. In addition, direct injuries to peripheral nerves , skin, viscera, and bone need to be considered.

Vascular injuries involve sites anywhere in the body, including structures in the neck , scalp, compartmental sites in the extremities, and viscera. Posttraumatic subarachnoid hemorrhages (aneurysmal) are not common and rarer still are traumatic dural sinus thromboses . Deep venous thromboses and vascular insufficiency syndromes can all lead to pain.

Degenerative changes involve those primarily of the neck and back that existed before the injury. Diskogenic, facet, and structural concerns can be exacerbated or initiated after trauma.

Congenital problems are mentioned as part of the differential diagnosis, although they have a minor role unless a pre-existing problem is involved. This involvement is noted in the pediatric types of brain injury and those with structural problems.

Metabolic conditions are important, mostly as contributors to other conditions. Hyper- and hypothyroid conditions (seen after severe TBI) contribute to neuropathy. Renal, hepatic, magnesium, and calcium alterations can lead to seizures (manifesting as headaches, behavioral conditions, confusion) or cognitive problems. Gastrointestinal (constipation) and genitourinary (urinary retention) systems can be involved with patient discomfort.

Infectious sites are primarily the lungs and bladder, but any surgical area can involve superficial or deep tissue problems with regional sites involved. Areas of particular importance are the sites of extracranial ventricular drains, ventricular-peritoneal drains (intracranially and intra-abdominally), intracranial monitors, intravenous and intra-arterial sites, all drainage tubes, and suture lines. Abrasions, fractures, and injured joints should be assessed. Meningitis, encephalitis, abscesses, diskitis, and sinusitis can all occur after TBI and require careful consideration.

Iatrogenic sources cause more metabolic and behavioral conditions than actual pain. This category includes treating with multiple medicines, especially from similar categories simultaneously. A “medication overuse headache” has also been coined .

Psychiatric causes need to be considered at all times, more commonly in the post acute settings. Because it is subjective, pain is always being questioned, especially in the chronic phase (usually defined after 6 months of continuous symptoms). The effects of posttraumatic stress, anxiety, and depression on pain have been explored by many researchers , as have the effects of motivation. Many psychologic and neuropsychologic tests are available to assist in this difficult assessment .

Painful dysimmune conditions exist primarily as vasculopathies, mononeuropathies, and mononeuritis multiplex as part of prior medical conditions. Exacerbations or initial presentation of certain potentially painful dysimmune problems (multiple sclerosis) after TBI have been debated without final resolution .

Neoplastic conditions need only be considered if trauma has occurred in the patient with a pre-existing condition. The need to appreciate two co-existing problems should not detract from an aggressive work-up of the cause of pain.

Neurologic conditions that can lead to pain include migraines, hydrocephalus, subdural hematomas, subdural hygromas, epidural hematomas, pneumocephalus, raised intracranial pressure, cerebrospinal fluid leakage with infection, seizures, cranial and spinal nerve involvement, meningeal irritation or infection, cerebral artery inflammation, lesser and greater occipital nerve bruising , supraorbital and supratrochlear nerve injury (ophthalmic division of the trigeminal nerve), radiculopathy, plexopathy, neuropathy, and complex regional pain syndrome. The trigeminal nerve innervates the sinuses, connects with the upper cervical spinal nerves (perhaps as far down as C3), and is considered one of the prime generators of migraines. Sinus clouding on radiographs after TBI is frequent but never singularly studied as a painful condition after trauma.

Musculoskeletal conditions involve structures of the neck (cervicogenic syndromes) that can involve the facets, foraminal tightness, disks, muscles, and ligaments , biomechanical aberrations at all locations of the vertebral column, tension headaches , tendonitis, adhesive capsulitis, myofascial syndromes , and temporomandibular joint (TMJ) syndrome.

Evaluation

It is traditionally taught that 80% of a diagnosis is based on history, with 10% each for the physical examination and requested tests. Often, the determination in the acute setting of having incurred a brain injury is made solely on what the CT or MRI demonstrates. In brain injury, especially for mild or moderate levels of injury, this can result is underdiagnosing or incorrectly diagnosing diffuse axonal injuries. Frontal lobe injuries are more easily and correctly diagnosed with the history and neuropsychologic examinations. The deep tendon reflex study will alert the examiner (with the observed hyperreflexia) to injury on the “normal” side (per CT or MRI). Similarly, pain cannot not be diagnosed accurately with current technology but only inferred. This issue is especially relevant in a population that may not be able to express themselves clearly, chronologically, and historically correct.

Listening to the patient (or caregiver/family member) is the most difficult part of the evaluation. It can be time consuming, confusing, and illogical. It is not unusual to hear about several sites of pain beginning days to weeks after the injury (usually secondary problems or biomechanical in origin). The patient may not have a clear memory or precise localization of every site that occurred during the acute phase.

Prior injury information (premorbid records) is always appreciated but infrequently available on the initial evaluation. Each site examined must include information about the character of the pain (sharp, dull, knotting, burning, twisting), the location, exacerbating and remitting factors, and intensity. Verbal or visual analogue scales are traditionally used, with “0” being no pain and “10” being suicidal/unbearable pain (or of such a level that an intravenous or emergency room visit is necessary if sustained). Periodicity (time of day, weather), rhythmicity (overall pattern to the events over time or during the day, week, or month), associated factors (nausea, vomiting, diaphoresis), and duration are also recorded. The mnemonic COLDER & FAT for Character, Onset, Location, Duration, Exacerbation, Relief, Functional activities affected, Associated symptoms, and Time has been used .

Pain drawings and filling out a visual or verbal analogue scale are recommended on each visit to objectify changes. Even sites that are drawn and are clearly outside the anatomic maps should not be discounted as fictional. Referral areas, commonly seen in myofascial injuries, do not follow traditional dermatomes. One accepts these referral patterns for myocardial pain (jaw, left arm, or fifth digit discomfort) but quickly dismisses the patient with pain as having non-anatomic complaints.

It is imperative to obtain information about the present pain, with full descriptors of the discomfort and how the descriptors have or have not changed over time. For example, a patient may state that his or her back pain used to be “sharp” and radiating down the leg but is now “dull” and localized to a particular region. Because pain is a dynamic situation, it is important to determine how each area has affected other regions. When inquiring about the maximal discomfort level of each site, one should ask how long that maximal pain period lasts (seconds, minutes, hours, days). One should ask about the highest and lowest levels of pain for each site, because there may be periods when the patient has no pain (time of day, activity related). Commonly, pain occurs in regions. The neck and shoulder sites will radiate to the head, arms, and midback. Most patients have one or two major sites (unless fractures occur), which, with proper treatment, will be more manageable.

If all sites of discomfort are not recognized and properly treated, the patient will continue to have pain. In an analogous way, if each and every room of a house on fire is not extinguished, the house will smolder or burn down. Unfortunately, hasty and regional treatment approaches to pain result in a protracted course with secondary consequences. One goal of treating the pain is symptom relief, but just as important is the return of function. Functional improvements can directly or indirectly affect behavior and cognition (eg, fewer medications, treatment sessions, spasticity). Inadequate and incomplete treatment strategies result in more therapy, medicine, and frustration.

Many patients will “overdo” their symptoms on initial examination to emphasize their distress. Over time, as one gets to know the patient and family, it is hoped that the focus moves from only pain complaints to functional gains. The patient’s need to overdo their pain complaints and report high analogue numbers should diminish over time (if he or she is forthright and honestly trying to improve). This progress is also dependent on the trust developed during the first visit. Unfortunately, many patients complain of having consulted multiple practitioners who have spent minimal time with them, focused on tests or procedures, performed a cursory physical examination, or not examined the multitude of sites required to understand the problem.

During the history taking, one needs to observe the distractibility of the patient. Frontal lobe injury is assumed to be one of the sites responsible for such activity. This distractibility not only complicates the treatment plan but may require the use of adjuvant therapies and medicines. This examiner purposely keeps the door open (initially) to indirectly assess this problem. The more the patient follows the examiner’s hand gesticulations in conversation, the more distractible the patient and (possibly) the lower the chances of overall success.

The physical examination should include a musculoskeletal evaluation and a neurologic assessment. Most conditions will fall into the former category, but the latter is important so as to not miss significant lesions. In addition, part of the “trick” of treating pain is to know what is anatomically possible and what is functionally based. Several tests on the neurologic examination can help to identify exaggerations or more conscious malingering. It is only the preponderance of evidence that convinces the examiner, family, jury, or claims adjustor of the patient’s veracity. Selective footage by surveillance cameras may not necessarily provide an accurate picture when pain is involved. Combining the examination, history, tests, and additional evidence provides the best way to understand and appreciate the patient’s condition.

A full general assessment is required with a listing of each and every scar, size measurements of involved limbs, and surgical wounds. Bruit auscultation is necessary for all patients having a brain injury and includes listening to the carotid, vertebral, temporal, orbital, and parietal/scalp sites . Skin sensitivity, facial responses, changes in position, and vocalities should be documented.

The neurologic examination should include a survey of its seven systems, usually beginning with the mini-mental evaluation. The latter helps set the tone for the rest of the examination. This evaluation is followed by studying gait. Standard heel, toe, and tandem attempts are made, noting arm movements, antalgia, balance difficulties, and symmetry. The Romberg test should be done initially with the eyes open (to assist with cerebellar involvements), followed by having the eyes closed (to aide with posterior column/proprioceptive diagnoses). More complex testing of balance can be done (one leg stance for 10 seconds, advanced Romberg tests) to help assess full participation and muscular strength in an alternative manner. Consistency is expected. If one finds diminished arm movement or posturing, the reflex hammer should correlate with motor system changes somewhere in the central nervous system; however, with local pain, attenuated movements of the arm or leg can be appreciated. The seven parts of the neurologic examination cross-index well to assist with the evaluation.

The cranial nerves should be examined, regardless of the site of injury and pain. Difficulties with vision, hearing, and balance can negatively affect balance, symmetry, and body position, resulting in compensatory movements. The extraocular muscles, corneal reflexes, visual acuities, facial movements, and sensation all need to be assessed. Recognizing a Horner’s syndrome in a darkened room will help focus the examiner on cervical cord involvement (if not present soon after the brain injury). Looking at the boundaries of the mandibular branch of the trigeminal nerve is important for it does not project posterior to the angle of the mandible. Inclusion of this site may assist in the overall assessment of the feigning patient. Checking the pterygoid muscle is a quick and telling way to determine TMJ dysfunction . This site can be easily forgotten, but its distribution of pain extends far beyond the mandibular condyle . It can cause head pain and headaches and can radiate to the neck, temporalis regions, and beyond. A formal assessment by persons specializing in the condition is extremely helpful. Incorrectly fitting orthotic splints by those not specializing in TMJ can sometimes cause more harm than good. A small change in the joint can sometimes out distance other problems noted in the head and neck. In addition, without this problem being addressed quickly and correctly, success rates for regional concerns involving sites from the midback, cephalad, drop off quickly. Checking the sternocleidomastoid muscles can be revealing for those patients whose credibility is in question. Assessing both rotational and downward/diagonal movements can help decide whether the contralateral sternocleidomastoid muscles (former) or ipsilateral (latter) muscles are involved. Segmental results on the forehead while testing with the tuning fork should also alert the examiner to exaggeration or feigning.

The motor examination should be a combination of the gait examination (performed previously) and formal testing of the muscle. One should attempt to assess range of motion (ROM) and strength in direct and indirect ways and record the range achieved passively and actively. Use of a goniometer or other measuring tool is strongly encouraged to document change. These data are helpful for the patient, family, and sometimes the court. Some examiners feel that aggressively testing a patient’s true ROM is closer to the truth. Although this assumption may be correct, the patient may incur injury and harbor resentment and distrust that may be difficult to change. Having the patient demonstrate their functional range is important, because it provides additional insight to psychologic and physical barriers. Slowly ranging the patient until he or she is uncomfortable is recommended (then measured). If one is truly interested in contractures, the above mentioned approach is encouraged. It is important to know what is considered a functional range (ie, 90 degrees for shoulder flexion and abduction). Writing appropriate functional goals for a patient in pain requires knowledge of the patient’s strength, ROM, and level of independence. The hand-held dynamometer can be used to test strength with the measurements recorded. The results can be subject to many factors (eg, pain levels, medicines taken, weather, or recent overuse of the area). Recording the measurements once (ie, during an independent medical examination) may provide spurious and tainted results. Asking an occupational therapist or other specialist who uses the tool regularly to perform the test on several occasions may provide a more accurate recording.

The sensory examination is of limited use owing to its subjective nature, but proprioception and vibration can be noted. Monofilaments can also assist to document sensation or discomfort. Proprioception should start at the most distal joint and continue proximally until the results are accurate and quickly voiced. Patients who have significant cognitive issues or who are exaggerating or feigning will be inconsistent or incapable of the cognitive step required in the test. Reporting areas of allodynia , hyperalgesia, hyperpathia, dysesthesias, and parathesias is helpful for record keeping, understanding the etiology of the problem, and treatment. When testing patients who have inconsistent examinations, alternating which side the examiner tests last may provide additional insight. Typically, the side last touched will produce a more vivid memory and will be reported as more sensitive.

Performing a deep tendon reflex examination is strongly encouraged, provided one uses the hammer gently. Subtleties are only seen and appreciated with soft uses of the hammer. Tendons commonly examined include those of the biceps, triceps, brachioradialis, finger flexors, pectoralis, suprapatellar, patellae, hamstrings, and Achilles. Due to the nature of central and peripheral injuries, the ability to clearly differentiate sites of injury requires that many areas be inspected and recorded. Identifying peripheral injury is not rare in patients who have incurred such severe injury.

The cerebellar test can be used to identify brainstem and cerebellar sites and to quietly test other muscle groups.

After the initial evaluation, it is common to order a series of tests to validate or assist with the diagnosis. In the acute situation, many of the required tests have yet to be ordered. Baseline CT, MRI, and electromyography/nerve conduction velocities are needed to assess peripheral versus central lesions. In addition, a bone scan may be of help to look for early stages of heterotopic ossification and as a general survey for fractures . In the chronic stages, most of these tests have been ordered, and repeating the studies should only be done if one suspects changes over time. Too frequently, an expensive study is requested when the physical examination would have suggested a source. A clear and precise examination can help differentiate central from peripheral lesions, levels of the brain versus the spinal cord, lesions within the nervous system as opposed to outside, and metabolic versus structural lesions. Having a solid differential diagnosis is essential to limit costs, inconveniences, and possibly discomfort of the patient. This process includes the use of diagnostic and therapeutic blocks. Going on a “fishing expedition” with, for example, cervical or lumbar epidural steroid injections without a strong suggestion of a radicular or diskogenic lesion should be discouraged. Contrariwise, using occipital blocks to help differentiate myofascial versus neurologic versus skeletal lesions of the neck is a more prudent use of time and money. Another example is the use of facet injections if pain is noted in the paraspinal areas with frequent changes on radiographs, negative electromyography, and changes with either manipulation or extension positioning. Chemical sympathectomies (eg, a stellate ganglion block) for possible complex regional pain syndrome are an appropriate diagnostic and therapeutic procedure. Frequent invasive procedures need to be questioned by all parties involved if the results are temporary or without merit. After TBI, many patients have been in the hospital or outpatient settings for extensive periods of time and prefer not to be aggressively studied or treated.