Can collaborative care reduce pain interference after traumatic brain injury?

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Chronic pain after traumatic brain injury (TBI) is common and associated with poor outcomes. Collaborative care (CC) may reduce pain interference by providing multidisciplinary care through expert consultation. The study compared CC with usual care (UC) for reducing pain interference.

This randomized clinical trial took place from July 2018 through April 2021 at two hospital-based academic rehabilitation medicine clinics in Seattle, Washington. Participants were adults with chronic pain and mild-to-severe TBI that had occurred at least 6 months before enrollment. Data were analyzed from March 30, 2022, to August 30, 2023.

The CC intervention, called TBI Care, offered up to 12 in-person or telephone visits over 16 weeks with a care manager who provided person-centered cognitive behavioral treatment. The care manager met weekly with an expert team to review participants and discuss recommendations to optimize treatment.

The primary outcome was pain interference measured with the Brief Pain Inventory at the end of treatment, 4 months after randomization. Secondary outcomes included pain interference at 8 months; pain severity; symptoms of depression, anxiety, and sleep disturbance; pain-related emergency department visits; community participation; and participant satisfaction. The researchers used linear mixed-effects regression for analysis.

Of 1,379 people screened for eligibility, 158 were randomized: 79 to CC and 79 to UC. Most participants were women (92, or 58%); their mean (SD) age was 46.8 (13.2) years, and mean (SD) education was 15.3 (3.0) years. TBI had occurred a mean (SD) of 4.0 (5.9) years before enrollment, with a median (IQR) of 1.9 (0.8–4.5) years. All TBI severities were included; among the 149 participants whose severity was known, 97 (65%) had mild TBI.

In the CC group, 71 participants (90%) completed at least 11 sessions. At 4 months, mean (SD) pain interference scores were significantly lower with CC than UC: 3.46 (2.17) versus 5.03 (2.28). The difference was maintained at 8 months, when mean (SD) scores were 3.61 (2.22) for CC versus 4.68 (2.51) for UC.

At 4 months, CC also had significantly lower mean (SD) scores than UC for pain severity (3.63 [1.95] vs 4.90 [1.96]), depression symptoms (8.07 [5.34] vs 11.31 [6.37]), and anxiety symptoms (6.20 [5.17] vs 9.58 [6.00]). Satisfaction was significantly higher with CC than UC for pain treatment (mean [SD], 2.99 [1.23] vs 2.52 [1.25]), clinical care (3.28 [1.00] vs 2.84 [1.26]), and overall health care (3.25 [0.88] vs 2.82 [1.00]). The global impression of change score was significantly lower with CC than UC (mean [SD], 2.74 [1.02] vs 3.47 [1.26]); lower scores indicate a better impression of change.

The researchers concluded that CC reduced pain interference compared with UC, with the effect sustained at the 8-month follow-up. Further research is needed on implementing CC for TBI and its cost-effectiveness in other health care settings. The trial was registered at ClinicalTrials.gov as NCT03523923.