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Bigford GE, Betancourt LF, Charlifue S, Nash MS. Therapeutic Lifestyle Intervention Targeting Enhanced Cardiometabolic Health and Function for Persons with Chronic Spinal Cord Injury in Caregiver/Care-Receiver Co-Treatment: A Study Protocol of a Multisite Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6819. [PMID: 37835090 PMCID: PMC10572441 DOI: 10.3390/ijerph20196819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/13/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Chronic spinal cord injury (SCI) significantly accelerates morbidity and mortality, partly due to the increased risk of cardiometabolic diseases (CMD), including neurogenic obesity, dyslipidemia, and impaired glucose metabolism. While exercise and dietary interventions have shown some transient benefits in reducing CMD risk, they often fail to improve clinically relevant disease markers and cardiovascular events. Moreover, SCI also places caregiving demands on their caregivers, who themselves experience health and functional decline. This underscores the need for more substantial interventions that incorporate appropriate physical activity, heart-healthy nutrition, and behavioral support tailored to the SCI population. OBJECTIVES This randomized clinical trial (RCT) protocol will (1) assess the health and functional effects, user acceptance, and satisfaction of a 6-month comprehensive therapeutic lifestyle intervention (TLI) adapted from the National Diabetes Prevention Program (DPP) for individuals with chronic SCI and (2) examine the impact of a complementary caregiver program on the health and function of SCI caregivers and evaluate user acceptance and satisfaction. Caregivers (linked with their partners) will be randomized to 'behavioral support' or 'control condition'. METHODS Dyadic couples comprise individuals with SCI (18-65 years, >1-year post-injury, ASIA Impairment Scale A-C, injury levels C5-L1) and non-disabled SCI caregivers (18-65 years). Both groups undergo lock-step circuit resistance training, a calorie-restricted Mediterranean-style diet, and 16 educational sessions focused on diet/exercise goals, self-monitoring, psychological and social challenges, cognitive behavioral therapy, and motivational interviewing. The outcome measures encompass the cardiometabolic risks, cardiorespiratory fitness, inflammatory stress, multidimensional function, pain, life quality, independence, self-efficacy, program acceptance, and life satisfaction for SCI participants. The caregiver outcomes include multidimensional function, pain, quality of life, independence, and perceived caregiver burden. DISCUSSION/CONCLUSIONS This study evaluates the effects and durability of a structured, multi-modal intervention on health and function. The results and intervention material will be disseminated to professionals and consumers for broader implementation. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02853149 Registered 2 August 2016.
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Affiliation(s)
- Gregory E. Bigford
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (L.F.B.); (M.S.N.)
| | - Luisa F. Betancourt
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (L.F.B.); (M.S.N.)
| | | | - Mark S. Nash
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (L.F.B.); (M.S.N.)
- Department of Physical Medicine & Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33101, USA
- Department of Physical Therapy, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Cherup NP, Robayo LE, Vastano R, Fleming L, Levin BE, Widerström-Noga E. Neuropsychological Function in Traumatic Brain Injury and the Influence of Chronic Pain. Percept Mot Skills 2023; 130:1495-1523. [PMID: 37219529 DOI: 10.1177/00315125231174082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Cognitive dysfunction, pain, and psychological morbidity all present unique challenges to those living with traumatic brain injury (TBI). In this study we examined (a) the impact of pain across domains of attention, memory, and executive function, and (b) the relationships between pain and depression, anxiety, and post-traumatic stress disorder (PTSD) in persons with chronic TBI. Our sample included 86 participants with a TBI and chronic pain (n = 26), patients with TBI and no chronic pain (n = 23), and a pain-free control group without TBI (n = 37). Participants visited the laboratory and completed a comprehensive battery of neuropsychological tests as part of a structured interview. Multivariate analysis of covariance using education as a covariate, failed to detect a significant group difference for neuropsychological composite scores of attention, memory, and executive function (p = .165). A follow-up analysis using multiple one-way analysis of variance (ANOVA) was conducted for individual measures of executive function. Post-hoc testing indicated that those in both TBI groups preformed significantly worse on measures of semantic fluency when compared to controls (p < 0.001, ηρ2 = .16). Additionally, multiple ANOVAs indicated that those with TBI and pain scored significantly worse across all psychological assessments (p < .001). We also found significant associations between measures of pain and most psychological symptoms. A follow-up stepwise linear regression among those in the TBI pain group indicated that post concussive complaints, pain severity, and neuropathic pain symptoms differentially contributed to symptoms of depression, anxiety, and PTSD. These findings suggest deficits in verbal fluency among those living with chronic TBI, with results also reinforcing the multidimensional nature of pain and its psychological significance in this population.
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Affiliation(s)
- Nicholas P Cherup
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Linda E Robayo
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Roberta Vastano
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Loriann Fleming
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Bonnie E Levin
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eva Widerström-Noga
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, USA
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3
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Widerström-Noga E, Anderson KD, Robayo LE, Perez S, Martinez-Arizala A, Calle-Coule L, Cherup NP, Fernandez GE. Development of a pain education resource for people with spinal cord injury. Front Public Health 2023; 11:1197944. [PMID: 37554730 PMCID: PMC10406314 DOI: 10.3389/fpubh.2023.1197944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/07/2023] [Indexed: 08/10/2023] Open
Abstract
Many people with spinal cord injury (SCI) develop chronic pain, including neuropathic pain. Unfortunately, current treatments for this condition are often inadequate because SCI-associated neuropathic pain is complex and depends on various underlying mechanisms and contributing factors. Multimodal treatment strategies including but not limited to pharmacological treatments, physical rehabilitation, cognitive training, and pain education may be best suited to manage pain in this population. In this study, we developed an educational resource named the SeePain based on published pain literature, and direct stakeholder input, including people living with SCI and chronic pain, their significant others, and healthcare providers with expertise in SCI. The SeePain was then 1) systematically evaluated by stakeholders regarding its content, comprehensibility, and format using qualitative interviews and thematic analysis, and 2) modified based on their perspectives. The final resource is a comprehensive guide for people with SCI and their significant others or family members that is intended to increase health literacy and facilitate communication between SCI consumers and their healthcare providers. Future work will quantitatively validate the SeePain in a large SCI sample.
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Affiliation(s)
- Eva Widerström-Noga
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Kimberly D. Anderson
- Department of Physical Medicine and Rehabilitation, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Linda E. Robayo
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Salome Perez
- Research Service, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL, United States
| | - Alberto Martinez-Arizala
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Lindsey Calle-Coule
- Research Service, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL, United States
| | - Nicholas P. Cherup
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gabriel E. Fernandez
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
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4
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Skiadopoulos A, Famodimu GO, Solomon SK, Agarwal P, Harel NY, Knikou M. Priming locomotor training with transspinal stimulation in people with spinal cord injury: study protocol of a randomized clinical trial. Trials 2023; 24:145. [PMID: 36841773 PMCID: PMC9960224 DOI: 10.1186/s13063-023-07193-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/20/2023] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND The seemingly simple tasks of standing and walking require continuous integration of complex spinal reflex circuits between descending motor commands and ascending sensory inputs. Spinal cord injury greatly impairs standing and walking ability, but both improve with locomotor training. However, even after multiple locomotor training sessions, abnormal muscle activity and coordination persist. Thus, locomotor training alone cannot fully optimize the neuronal plasticity required to strengthen the synapses connecting the brain, spinal cord, and local circuits and potentiate neuronal activity based on need. Transcutaneous spinal cord (transspinal) stimulation alters motoneuron excitability over multiple segments by bringing motoneurons closer to threshold, a prerequisite for effectively promoting spinal locomotor network neuromodulation and strengthening neural connectivity of the injured human spinal cord. Importantly, whether concurrent treatment with transspinal stimulation and locomotor training maximizes motor recovery after spinal cord injury is unknown. METHODS Forty-five individuals with chronic spinal cord injury are receiving 40 sessions of robotic gait training primed with 30 Hz transspinal stimulation at the Thoracic 10 vertebral level. Participants are randomized to receive 30 min of active or sham transspinal stimulation during standing or active transspinal stimulation while supine followed by 30 min of robotic gait training. Over the course of locomotor training, the body weight support, treadmill speed, and leg guidance force are adjusted as needed for each participant based on absence of knee buckling during the stance phase and toe dragging during the swing phase. At baseline and after completion of all therapeutic sessions, neurophysiological recordings registering corticospinal and spinal neural excitability changes along with clinical assessment measures of standing and walking, and autonomic function via questionnaires regarding bowel, bladder, and sexual function are taken. DISCUSSION The results of this mechanistic randomized clinical trial will demonstrate that tonic transspinal stimulation strengthens corticomotoneuronal connectivity and dynamic neuromodulation through posture-dependent corticospinal and spinal neuroplasticity. We anticipate that this mechanistic clinical trial will greatly impact clinical practice because, in real-world clinical settings, noninvasive transspinal stimulation can be more easily and widely implemented than invasive epidural stimulation. Additionally, by applying multiple interventions to accelerate motor recovery, we are employing a treatment regimen that reflects a true clinical approach. TRIAL REGISTRATION ClinicalTrials.gov NCT04807764 . Registered on March 19, 2021.
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Affiliation(s)
- Andreas Skiadopoulos
- grid.254498.60000 0001 2198 5185Klab4Recovery Research Program, The City University of New York, College of Staten Island, Staten Island, NY USA ,grid.254498.60000 0001 2198 5185Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY USA
| | - Grace O. Famodimu
- Spinal Cord Damage Research Center, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY USA
| | - Shammah K. Solomon
- grid.254498.60000 0001 2198 5185Klab4Recovery Research Program, The City University of New York, College of Staten Island, Staten Island, NY USA ,grid.254498.60000 0001 2198 5185Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY USA
| | - Parul Agarwal
- grid.59734.3c0000 0001 0670 2351Population Health Science & Policy, Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, Manhattan, NY USA
| | - Noam Y. Harel
- Spinal Cord Damage Research Center, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY USA ,grid.59734.3c0000 0001 0670 2351Population Health Science & Policy, Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, Manhattan, NY USA
| | - Maria Knikou
- Klab4Recovery Research Program, The City University of New York, College of Staten Island, Staten Island, NY, USA. .,Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY, USA. .,PhD Program in Biology and Collaborative Neuroscience Program, Graduate Center of The City University of New York and College of Staten Island, Manhattan & Staten Island, NY, USA.
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5
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Skiadopoulos A, Famodimu GO, Solomon SK, Agrawal P, Harel NY, Knikou M. Priming locomotor training with transspinal stimulation in people with spinal cord injury: study protocol of a randomized clinical trial. RESEARCH SQUARE 2023:rs.3.rs-2527617. [PMID: 36824823 PMCID: PMC9949167 DOI: 10.21203/rs.3.rs-2527617/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background The seemingly simple tasks of standing and walking require continuous integration of complex spinal reflex circuits between descending motor commands and ascending sensory inputs. Spinal cord injury greatly impairs standing and walking ability, but both improve with locomotor training. However, even after multiple locomotor training sessions, abnormal muscle activity and coordination persist. Thus, locomotor training alone cannot fully optimize the neuronal plasticity required to strengthen the synapses connecting the brain, spinal cord, and local circuits and potentiate neuronal activity based on need. Transcutaneous spinal cord (transspinal) stimulation alters motoneuron excitability over multiple segments by bringing motoneurons closer to threshold, a prerequisite for effectively promoting spinal locomotor network neuromodulation and strengthening neural connectivity of the injured human spinal cord. Importantly, whether concurrent treatment with transspinal stimulation and locomotor training maximizes motor recovery after spinal cord injury is unknown. Methods Forty-five individuals with chronic spinal cord injury are receiving 40 sessions of robotic gait training primed with 30 Hz transspinal stimulation at the Thoracic 10 vertebral level. Participants are randomized to receive 30-minutes of active or sham transspinal stimulation during standing or active transspinal stimulation while supine followed by 30-minutes of robotic gait training. Over the course of locomotor training, the body weight support, treadmill speed, and leg guidance force are adjusted as needed for each participant based on absence of knee buckling during the stance phase and toe dragging during the swing phase. At baseline and after completion of all therapeutic sessions, neurophysiological recordings registering corticospinal and spinal neural excitability changes along with clinical assessment measures of standing and walking, and autonomic function via questionnaires regarding bowel, bladder and sexual function are taken. Discussion The results of this mechanistic randomized clinical trial will demonstrate that tonic transspinal stimulation strengthens corticomotoneuronal connectivity and dynamic neuromodulation through posture-dependent corticospinal and spinal neuroplasticity. We anticipate that this mechanistic clinical trial will greatly impact clinical practice because in real-world clinical settings, noninvasive transspinal stimulation can be more easily and widely implemented than invasive epidural stimulation. Additionally, by applying multiple interventions to accelerate motor recovery, we are employing a treatment regimen that reflects a true clinical approach. Trial registration ClinicalTrials.gov: NCT04807764; Registered on March 19, 2021.
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Affiliation(s)
| | | | | | - Parul Agrawal
- Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy
| | - Noam Y Harel
- James J Peters VAMC: James J Peters VA Medical Center
| | - Maria Knikou
- College of Staten Island School of Health Sciences
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Olusanya A, Yearsley A, Brown N, Braun S, Hayes C, Rose E, Connolly B, Dicks M, Beal C, Helmonds B, Peace W, Kirkman B, Nguyen C, Erickson J, Nguyen G, Lukose E, Koek W, Nagpal AS, Trbovich M. Capsaicin 8% Patch for Spinal Cord Injury Focal Neuropathic Pain, a Randomized Controlled Trial. PAIN MEDICINE 2023; 24:71-78. [PMID: 35799365 DOI: 10.1093/pm/pnac104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neuropathic pain (NP) after spinal cord injury (SCI) exacerbates disability, decreases quality of life (QOL), and is often refractory to available therapies. Patients report willingness to trade potential recovery of strength, bowel, bladder, or sexual function for pain relief. One proposed mechanism causing NP is up-regulation of transient receptor potential vanilloid 1 (TRPV 1) proteins in uninjured C fibers and dorsal root ganglia causing neuronal excitability. Recent studies have found up-regulation of TRPV 1 proteins after SCI. OBJECTIVE We hypothesize the application of capsaicin 8% patch (C8P), FDA approved for NP in diabetic peripheral neuropathy and post-herpetic neuralgia, will improve pain, function and QOL in persons with SCI. METHODS Randomized single-blind crossover design in which 11 persons with SCI and NP refractory to two oral pain medications received C8P or a control low dose Capsaicin 0.025% patch (CON) over two 12-week periods. Pain (VAS, MPI-SCI), quality of life (WHO-QOL), and functional status (SCIM) were measured at 2-4-week intervals. RESULTS There was a main treatment effect of C8P over CON on VAS and MPI-SCI outcomes with pain reduction of 35% and 29% at weeks 2 and 4, respectively. C8P also demonstrated a main treatment effect over CON on the SCIM mobility subscale. WHO-QOL scores did not improve with C8P. CONCLUSIONS C8P improves pain and mobility for patients with SCI and refractory NP. Larger studies should be performed to evaluate impact of repeat applications and QOL outcomes.
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Affiliation(s)
- Adedeji Olusanya
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Aaron Yearsley
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Nicholas Brown
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Samantha Braun
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Corey Hayes
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Evon Rose
- University of the Incarnate World Osteopathic Medical School, San Antonio, Texas, USA
| | - Brian Connolly
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Madeline Dicks
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Colby Beal
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Brett Helmonds
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Wesley Peace
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Bryce Kirkman
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Christina Nguyen
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jacob Erickson
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Gabby Nguyen
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Esha Lukose
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Wouter Koek
- The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Ameet S Nagpal
- Department of Orthopedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michelle Trbovich
- Physical Medicine and Rehabilitation, UTHSC at San Antonio, San Antonio, Texas, USA
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7
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Robayo LE, Govind V, Vastano R, Felix ER, Fleming L, Cherup NP, Widerström-Noga E. Multidimensional pain phenotypes after Traumatic Brain Injury. FRONTIERS IN PAIN RESEARCH 2022; 3:947562. [PMID: 36061413 PMCID: PMC9437424 DOI: 10.3389/fpain.2022.947562] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/02/2022] [Indexed: 12/04/2022] Open
Abstract
More than 50% of individuals develop chronic pain following traumatic brain injury (TBI). Research suggests that a significant portion of post-TBI chronic pain conditions is neuropathic in nature, yet the relationship between neuropathic pain, psychological distress, and somatosensory function following TBI is not fully understood. This study evaluated neuropathic pain symptoms, psychological and somatosensory function, and psychosocial factors in individuals with TBI (TBI, N = 38). A two-step cluster analysis was used to identify phenotypes based on the Neuropathic Pain Symptom Inventory and Beck's Anxiety Inventory scores. Phenotypes were then compared on pain characteristics, psychological and somatosensory function, and psychosocial factors. Our analyses resulted in two different neuropathic pain phenotypes: (1) Moderate neuropathic pain severity and anxiety scores (MNP-AS, N = 11); and (2) mild or no neuropathic pain symptoms and anxiety scores (LNP-AS, N = 27). Furthermore, the MNP-AS group exhibited greater depression, PTSD, pain severity, and affective distress scores than the LNP-AS group. In addition, thermal somatosensory function (difference between thermal pain and perception thresholds) was significantly lower in the MNP-AS compared to the LNP-AS group. Our findings suggest that neuropathic pain symptoms are relatively common after TBI and are not only associated with greater psychosocial distress but also with abnormal function of central pain processing pathways.
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Affiliation(s)
- Linda E. Robayo
- Neuroscience Graduate Program, University of Miami Miller School of Medicine, Miami, FL, United States
- Christine E. Lynn Rehabilitation Center, Miami Project to Cure Paralysis at UHealth/Jackson Memorial, Miami, FL, United States
| | - Varan Govind
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Roberta Vastano
- Christine E. Lynn Rehabilitation Center, Miami Project to Cure Paralysis at UHealth/Jackson Memorial, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Elizabeth R. Felix
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Loriann Fleming
- Christine E. Lynn Rehabilitation Center, Miami Project to Cure Paralysis at UHealth/Jackson Memorial, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Nicholas P. Cherup
- Christine E. Lynn Rehabilitation Center, Miami Project to Cure Paralysis at UHealth/Jackson Memorial, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Eva Widerström-Noga
- Neuroscience Graduate Program, University of Miami Miller School of Medicine, Miami, FL, United States
- Christine E. Lynn Rehabilitation Center, Miami Project to Cure Paralysis at UHealth/Jackson Memorial, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- *Correspondence: Eva Widerström-Noga
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8
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Wong ML, Widerstrom-Noga E, Field-Fote EC. Effects of whole-body vibration on neuropathic pain and the relationship between pain and spasticity in persons with spinal cord injury. Spinal Cord 2022; 60:963-970. [PMID: 35468994 DOI: 10.1038/s41393-022-00806-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Whole-body vibration (WBV) appears to modulate reflex hyperexcitability and spasticity. Due to common underlying neural mechanisms between spasticity and neuropathic pain, WBV may also reduce chronic pain after spinal cord injury (SCI). Our objective was to determine whether there are dose-related changes in pain following WBV and to examine the relationships between neuropathic pain and reflex excitability. STUDY DESIGN Secondary analysis of a sub-population (participants with neuropathic pain, n = 16) from a larger trial comparing the effects of two different doses of WBV on spasticity in persons with SCI. SETTING Hospital/Rehabilitation Center in Atlanta, GA, USA. METHODS Participants were randomized to 8-bout or 16-bout WBV groups. Both groups received ten sessions of sham intervention, followed by ten sessions of WBV. Primary measures included the Neuropathic Pain Symptom Inventory (NPSI) for pain symptom severity and H-reflex paired-pulse depression (PPD) for reflex excitability. RESULTS Mean change in NPSI scores were not significantly different between the groups (7 ± 6; p = 0.29; ES = 0.57); however, 8-bouts of WBV were consistently beneficial for participants with high neuropathic pain symptom severity (NPSI total score >30), while 16-bouts of WBV appeared to increase pain in some individuals with high NPSI scores. A baseline NPSI cut score of 30 predicted PPD response (sensitivity = 1.0, specificity = 0.83), with higher NPSI scores associated with decreased PPD in response to WBV. CONCLUSIONS WBV in moderate doses appears to decrease neuropathic pain symptoms and improve reflex modulation. However, at higher doses neuropathic pain symptoms may be aggravated. Lower baseline NPSI scores were associated with improved reflex modulation.
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Affiliation(s)
- Marlon L Wong
- Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL, USA. .,Department of Physical Therapy, Miller School of Medicine, University of Miami, Miami, FL, USA.
| | - Eva Widerstrom-Noga
- Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL, USA.,Neuroscience Graduate Program, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Edelle C Field-Fote
- Shepherd Center, Crawford Research Institute, Atlanta, GA, USA.,Emory University School of Medicine, Division of Physical Therapy, Atlanta, GA, USA.,Georgia Institute of Technology, School of Biological Sciences, Atlanta, GA, USA
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9
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Widerstrom-Noga E, Anderson KD, Perez S, Martinez-Arizala A, Calle-Coule L, Fleming L. Barriers and Facilitators to Optimal Neuropathic Pain Management: SCI Consumer, Significant Other, and Health Care Provider Perspectives. PAIN MEDICINE 2021; 21:2913-2924. [PMID: 32219441 DOI: 10.1093/pm/pnaa058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Persistent neuropathic pain is a common and often severe consequence of spinal cord injury (SCI). There is a critical need to better understand how to overcome barriers and promote facilitators to optimal pain management. The present study was designed to identify, from the perspectives of persons living with SCI, their significant others, and SCI health care professionals, the barriers and facilitators to optimal pain management for intense neuropathic pain. DESIGN Qualitative interviews. SETTING University laboratory. SUBJECTS People with SCI who had experienced intense neuropathic pain for a minimum of a year (N = 15), their significant others (N = 15), and SCI health care providers (N = 15). METHODS Qualitative interviews were recorded, transcribed, and analyzed based on grounded theory using ATLAS.ti software. RESULTS Inadequate access to care, information, or pain management expertise were frequently perceived barriers to optimal pain management across all three groups. Another major barrier was SCI stakeholders' concerns regarding the risks of adverse effects and addiction to pain medication. Facilitators included having a better understanding of pain and available treatment options, effective patient-provider communication, resilience, and access to nonpharmacological treatment options. CONCLUSIONS Managing intense neuropathic pain poses significant challenges after SCI. SCI stakeholders felt that accessible treatment options were limited and primarily focused on pain medications with minimal benefit but with significant risks for addiction and adverse effects. Actionable facilitators to optimal pain management after SCI include education regarding neuropathic pain and treatment options for all stakeholders, better communication regarding neuropathic pain among stakeholders, and improved patient access to nonpharmacological treatment options.
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Affiliation(s)
- Eva Widerstrom-Noga
- The Miami Project to Cure Paralysis, The University of Miami, Miami, Florida.,Research Service, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida
| | - Kim D Anderson
- The Miami Project to Cure Paralysis, The University of Miami, Miami, Florida.,Department of Physical Medicine and Rehabilitation, Metrohealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Salome Perez
- Research Service, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida
| | - Alberto Martinez-Arizala
- The Miami Project to Cure Paralysis, The University of Miami, Miami, Florida.,Research Service, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida
| | - Lindsey Calle-Coule
- Research Service, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida
| | - Loriann Fleming
- The Miami Project to Cure Paralysis, The University of Miami, Miami, Florida
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10
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Tibbett JA, Field‐Fote EC, Thomas CK, Widerström‐Noga EG. Spasticity and Pain after Spinal Cord Injury: Impact on Daily Life and the Influence of Psychological Factors. PM R 2019; 12:119-129. [DOI: 10.1002/pmrj.12218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/30/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Jacqueline A. Tibbett
- The Miami Project to Cure Paralysis University of Miami Miami FL
- Department of Physiology and BiophysicsUniversity of Miami Miami FL
| | - Edelle C. Field‐Fote
- Shepherd Center, Crawford Research Institute Atlanta GA
- Division of Physical TherapyEmory University School of Medicine Atlanta GA
| | - Christine K. Thomas
- The Miami Project to Cure Paralysis University of Miami Miami FL
- Department of Physiology and BiophysicsUniversity of Miami Miami FL
- Department of Neurological SurgeryUniversity of Miami Miami FL
| | - Eva G. Widerström‐Noga
- The Miami Project to Cure Paralysis University of Miami Miami FL
- Department of Neurological SurgeryUniversity of Miami Miami FL
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11
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Wong ML, Fleming L, Robayo LE, Widerström-Noga E. Utility of the Neuropathic Pain Symptom Inventory in people with spinal cord injury. Spinal Cord 2019; 58:35-42. [DOI: 10.1038/s41393-019-0338-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 01/16/2023]
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12
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Best KL, Routhier F, Sweet SN, Lacroix E, Arbour-Nicitopoulos KP, Borisoff JF. Smartphone-Delivered Peer Physical Activity Counseling Program for Individuals With Spinal Cord Injury: Protocol for Development and Pilot Evaluation. JMIR Res Protoc 2019; 8:e10798. [PMID: 30901001 PMCID: PMC6450480 DOI: 10.2196/10798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/15/2018] [Accepted: 09/14/2018] [Indexed: 12/21/2022] Open
Abstract
Background Leisure-time physical activity (LTPA) is a critical component of a healthy lifestyle for individuals with spinal cord injury (SCI). However, most individuals are not sufficiently active to accrue health benefits. The Active Living Lifestyles program for individuals with SCI who use manual wheelchairs (ALLWheel) targets important psychological factors that are associated with LTPA uptake and adherence while overcoming some barriers associated with participation restrictions. Objective The goal of the paper is to describe the protocol for the development and evaluation of the ALLWheel program for individuals with SCI who use manual wheelchairs. Methods The first three stages of the Medical Research Council framework for developing and evaluating complex interventions (ie, preclinical, modeling, exploratory) are described. The preclinical phase will consist of scoping and systematic reviews and review of theory. The intervention will be modeled by expert opinions and consensus through focus groups and Delphi surveys with individuals with SCI, clinicians, and community partners. Finally, the feasibility and potential influence of the ALLWheel program on LTPA and psychological outcomes will be evaluated. Results This project is funded by the Craig H Neilsen Foundation, the Fonds de Recherche du Québec–Santé, and the Canadian Disability Participation Project and is currently underway. Conclusions Using peer trainers and mobile phone technology may help to cultivate autonomy-supportive environments that also enhance self-efficacy. Following a framework for developing and evaluating a novel intervention that includes input from stakeholders at all stages will ensure the final product (ie, a replicable intervention) is desirable to knowledge users and ready for evaluation in a randomized controlled trial. If effective, the ALLWheel program has the potential to reach a large number of individuals with SCI to promote LTPA uptake and adherence. International Registered Report Identifier (IRRID) DERR1-10.2196/10798
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Affiliation(s)
- Krista L Best
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Institut de Réadaptation en Déficience Physique de Québec, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale National, Quebec, QC, Canada.,Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - François Routhier
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Institut de Réadaptation en Déficience Physique de Québec, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale National, Quebec, QC, Canada.,Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Shane N Sweet
- Department of Kinesiology & Physical Education, McGill University, Montreal, QC, Canada.,Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain, Montreal, QC, Canada
| | - Emilie Lacroix
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Institut de Réadaptation en Déficience Physique de Québec, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale National, Quebec, QC, Canada
| | | | - Jaimie F Borisoff
- Rehabilitation Engineering Design Laboratory, British Columbia Institute of Technology, Burnaby, BC, Canada.,International Collaboration on Repair Discoveries, Vancouver Coastal Health, Vancouver, BC, Canada
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13
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Subgroup Perspectives on Chronic Pain and Its Management After Spinal Cord Injury. THE JOURNAL OF PAIN 2018; 19:1480-1490. [DOI: 10.1016/j.jpain.2018.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/13/2018] [Accepted: 07/13/2018] [Indexed: 11/18/2022]
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14
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Cohen ML, Kisala PA, Dyson-Hudson TA, Tulsky DS. Measuring pain phenomena after spinal cord injury: Development and psychometric properties of the SCI-QOL Pain Interference and Pain Behavior assessment tools. J Spinal Cord Med 2018; 41:267-280. [PMID: 28185477 PMCID: PMC6055945 DOI: 10.1080/10790268.2017.1279805] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To develop modern patient-reported outcome measures that assess pain interference and pain behavior after spinal cord injury (SCI). DESIGN Grounded-theory based qualitative item development; large-scale item calibration field-testing; confirmatory factor analyses; graded response model item response theory analyses; statistical linking techniques to transform scores to the Patient Reported Outcome Measurement Information System (PROMIS) metric. SETTING Five SCI Model Systems centers and one Department of Veterans Affairs medical center in the United States. PARTICIPANTS Adults with traumatic SCI. INTERVENTIONS N/A. OUTCOME MEASURES Spinal Cord Injury - Quality of Life (SCI-QOL) Pain Interference item bank, SCI-QOL Pain Interference short form, and SCI-QOL Pain Behavior scale. RESULTS Seven hundred fifty-seven individuals with traumatic SCI completed 58 items addressing various aspects of pain. Items were then separated by whether they assessed pain interference or pain behavior, and poorly functioning items were removed. Confirmatory factor analyses confirmed that each set of items was unidimensional, and item response theory analyses were used to estimate slopes and thresholds for the items. Ultimately, 7 items (4 from PROMIS) comprised the Pain Behavior scale and 25 items (18 from PROMIS) comprised the Pain Interference item bank. Ten of these 25 items were selected to form the Pain Interference short form. CONCLUSIONS The SCI-QOL Pain Interference item bank and the SCI-QOL Pain Behavior scale demonstrated robust psychometric properties. The Pain Interference item bank is available as a computer adaptive test or short form for research and clinical applications, and scores are transformed to the PROMIS metric.
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Affiliation(s)
- Matthew L. Cohen
- Department of Communication Sciences and Disorders, University of Delaware, Newark, Delaware, USA,Department of Psychological and Brain Sciences, University of Delaware, Newark, Delaware, USA,Center on Assessment Research and Translation, University of Delaware, Newark, Delaware, USA,Correspondence to: Matthew L. Cohen, 540 S. College Ave, Newark, DE 19713, USA.
| | - Pamela A. Kisala
- Center on Assessment Research and Translation, University of Delaware, Newark, Delaware, USA
| | - Trevor A. Dyson-Hudson
- Kessler Foundation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - David S. Tulsky
- Department of Psychological and Brain Sciences, University of Delaware, Newark, Delaware, USA,Center on Assessment Research and Translation, University of Delaware, Newark, Delaware, USA
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15
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Jermakowicz WJ, Hentall ID, Jagid JR, Luca CC, Adcock J, Martinez-Arizala A, Widerström-Noga E. Deep Brain Stimulation Improves the Symptoms and Sensory Signs of Persistent Central Neuropathic Pain from Spinal Cord Injury: A Case Report. Front Hum Neurosci 2017; 11:177. [PMID: 28428749 PMCID: PMC5382156 DOI: 10.3389/fnhum.2017.00177] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/27/2017] [Indexed: 01/05/2023] Open
Abstract
Central neuropathic pain (CNP) is a significant problem after spinal cord injury (SCI). Pharmacological and non-pharmacological approaches may reduce the severity, but relief is rarely substantial. While deep brain stimulation (DBS) has been used to treat various chronic pain types, the technique has rarely been used to attenuate CNP after SCI. Here we present the case of a 54-year-old female with incomplete paraplegia who had severe CNP in the lower limbs and buttock areas since her injury 30 years prior. She was treated with bilateral DBS of the midbrain periaqueductal gray (PAG). The effects of this stimulation on CNP characteristics, severity and pain-related sensory function were evaluated using the International SCI Pain Basic Data Set (ISCIPBDS), Neuropathic Pain Symptom Inventory (NPSI), Multidimensional Pain Inventory and Quantitative Sensory Testing before and periodically after initiation of DBS. After starting DBS treatment, weekly CNP severity ratings rapidly decreased from severe to minimal, paralleled by a substantial reduction in size of the painful area, reduced pain impact and reversal of pain-related neurological abnormalities, i.e., dynamic-mechanical and cold allodynia. She discontinued pain medication on study week 24. The improvement has been consistent. The present study expands on previous findings by providing in-depth assessments of symptoms and signs associated with CNP. The results of this study suggest that activation of endogenous pain inhibitory systems linked to the PAG can eliminate CNP in some people with SCI. More research is needed to better-select appropriate candidates for this type of therapy. We discuss the implications of these findings for understanding the brainstem's control of chronic pain and for future progress in using analgesic DBS in the central gray.
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Affiliation(s)
- Walter J Jermakowicz
- The Miami Project to Cure Paralysis, Miller School of Medicine, University of MiamiMiami, FL, USA.,Department of Neurological Surgery, Miller School of Medicine, University of MiamiMiami, FL, USA
| | - Ian D Hentall
- The Miami Project to Cure Paralysis, Miller School of Medicine, University of MiamiMiami, FL, USA.,Department of Neurological Surgery, Miller School of Medicine, University of MiamiMiami, FL, USA.,Research Service, Bruce W. Carter Department of Veterans Affairs Medical CenterMiami, FL, USA
| | - Jonathan R Jagid
- The Miami Project to Cure Paralysis, Miller School of Medicine, University of MiamiMiami, FL, USA.,Research Service, Bruce W. Carter Department of Veterans Affairs Medical CenterMiami, FL, USA
| | - Corneliu C Luca
- Research Service, Bruce W. Carter Department of Veterans Affairs Medical CenterMiami, FL, USA.,Department of Neurology, Miller School of Medicine, University of MiamiMiami, FL, USA
| | - James Adcock
- The Miami Project to Cure Paralysis, Miller School of Medicine, University of MiamiMiami, FL, USA.,Research Service, Bruce W. Carter Department of Veterans Affairs Medical CenterMiami, FL, USA
| | - Alberto Martinez-Arizala
- The Miami Project to Cure Paralysis, Miller School of Medicine, University of MiamiMiami, FL, USA.,Department of Neurological Surgery, Miller School of Medicine, University of MiamiMiami, FL, USA.,Research Service, Bruce W. Carter Department of Veterans Affairs Medical CenterMiami, FL, USA.,Department of Neurology, Miller School of Medicine, University of MiamiMiami, FL, USA
| | - Eva Widerström-Noga
- The Miami Project to Cure Paralysis, Miller School of Medicine, University of MiamiMiami, FL, USA.,Department of Neurological Surgery, Miller School of Medicine, University of MiamiMiami, FL, USA.,Research Service, Bruce W. Carter Department of Veterans Affairs Medical CenterMiami, FL, USA
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16
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Widerström-Noga E, Anderson KD, Perez S, Hunter JP, Martinez-Arizala A, Adcock JP, Escalona M. Living With Chronic Pain After Spinal Cord Injury: A Mixed-Methods Study. Arch Phys Med Rehabil 2016; 98:856-865. [PMID: 27894730 DOI: 10.1016/j.apmr.2016.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 10/20/2016] [Accepted: 10/25/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To identify the relative importance of positive (facilitators) and negative (barriers) contributors to living with chronic pain after spinal cord injury (SCI). DESIGN Mixed-methods: (1) Qualitative (n=35): individual, semistructured, open-ended interviews identifying facilitator/barrier themes; (2) Quantitative (n=491): converting the most common themes into statements and quantifying agreement with these in an online survey to determine relative importance, underlying dimensions, and their associations with perceived difficulty in dealing with pain. SETTING University-based research setting and general community. PARTICIPANTS Volunteers (N=526) with SCI experiencing moderate to severe chronic pain. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Interview guides, facilitator/barrier statements, and pain inventories. RESULTS Exploratory factor analyses reduced agreement ratings into 4 facilitators (information regarding pain and treatments, resilience, coping, medication use) and 5 barriers (poor health care communication, pain impact and limitations, poor communication about pain, difficult nature of pain, treatment concerns). Greater "pain impact and limitations," "difficult nature of pain," "poor communication from provider," lower "resilience," greater "medication use," and younger age predicted greater difficulty in dealing with pain (r=.75; F=69.02; P<.001). CONCLUSIONS This study revealed multiple facilitators and barriers to living with chronic pain after SCI. The principal barrier, "poor health care communication," indicated that consumers do not receive adequate information from their health care providers regarding pain. "Information regarding pain and treatments" had greater agreement scores and factor loadings than all other facilitators, indicating that most participants view provider-patient communication and educational efforts regarding pain and pain management as priorities and critical needs. Further initiatives in these areas are important for improving pain management post-SCI.
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Affiliation(s)
- Eva Widerström-Noga
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL; Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL; Bruce W. Carter Veterans Affairs Medical Center, Miami, FL.
| | - Kimberly D Anderson
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL; Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL; Bruce W. Carter Veterans Affairs Medical Center, Miami, FL
| | - Salomé Perez
- Bruce W. Carter Veterans Affairs Medical Center, Miami, FL
| | - Judith P Hunter
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Alberto Martinez-Arizala
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL; Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL; Bruce W. Carter Veterans Affairs Medical Center, Miami, FL
| | - James P Adcock
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL; Bruce W. Carter Veterans Affairs Medical Center, Miami, FL
| | - Maydelis Escalona
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL; Bruce W. Carter Veterans Affairs Medical Center, Miami, FL
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17
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Henriksson J, Wasara E, Rönnlund M. Effects of Eight-Week-Web-Based Mindfulness Training on Pain Intensity, Pain Acceptance, and Life Satisfaction in Individuals With Chronic Pain. Psychol Rep 2016; 119:586-607. [DOI: 10.1177/0033294116675086] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examined the effects of an eight-week-web-based mindfulness program designed for individuals with chronic pain. A sample of 107 participants with chronic pain ( M = 51.0 years, SD = 9.3) were randomly assigned to a treatment group and a control group. The mindfulness program involved 20 minutes of training per day, six days a week, for eight weeks. During this period, the control group was invited to an online discussion forum involving pain-related topics. A total of 77 participants completed the postintervention assessment ( n = 36 in the treatment group, n = 41 in the control group). The group assigned to mindfulness training showed increased mindfulness skills (Cohen’s d = 1.18), reduced pain intensity ( d = 0.47–0.82), reduced pain-related interference/suffering ( d = 0.39–0.85), heightened pain acceptance ( d = 0.66), reduced affective distress ( d = 0.67), and higher ratings of life satisfaction ( d = 0.54) following the training with no or minor changes up for the control group ( d values 0.01–0.23), a pattern substantiated by significant group-by-time interactions. Despite limitations of this study, including a less than ideal control group to isolate effects of mindfulness and lack of a long-term follow-up, the results appear promising and may motivate further investigations.
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Affiliation(s)
| | - Emma Wasara
- Department of Psychology, Umeå University, Umeå, Sweden
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18
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Widerström-Noga E, Cruz-Almeida Y, Felix ER, Pattany PM. Somatosensory phenotype is associated with thalamic metabolites and pain intensity after spinal cord injury. Pain 2015; 156:166-174. [PMID: 25599312 DOI: 10.1016/j.pain.0000000000000019] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neuropathic pain is one of the most difficult consequences of spinal cord injury (SCI). The clinical correlates of the underlying mechanisms responsible for neuropathic pain are not well understood, although methods such as quantitative somatosensory testing (QST) or brain imaging have been used to further a mechanism-based understanding of pain. Our previous SCI study demonstrated a significantly lower glutamate-glutamine/myo-inositol ratio (Glx/Ins) in the anterior cingulate cortex in persons with severe neuropathic pain compared with those with less severe neuropathic pain or pain-free, able-bodied controls, suggesting that a combination of decreased glutamatergic metabolism and glial activation may contribute to the development of severe neuropathic pain after SCI. The present study aimed to determine the relationships between somatosensory function below the level of injury and low thalamic Glx/Ins in persons with intense neuropathic pain after SCI. Participants underwent QST and a 3 Tesla proton magnetic resonance spectroscopy. A cluster analysis including SCI participants resulted in 1 group (n = 19) with significantly (P < 0.001) greater pain intensity (6.43 ± 1.63; high neuropathic pain [HNP], and lower Glx/Ins [1.22 ± 0.16]) and another group (n = 35) with lower pain intensity ratings (1.59 ± 1.52, low neuropathic pain [LNP], and higher Glx/Ins [1.47 ± 0.26]). After correcting for age, QST indicated significantly greater somatosensory function in the HNP group compared with the LNP group. Our results are consistent with research suggesting that damage to, but not abolition of, the spinothalamic tract contributes to development of neuropathic pain after SCI and that secondary inflammatory processes may amplify residual spinothalamic tract signals by facilitation, disinhibition, or sensitization.
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Affiliation(s)
- Eva Widerström-Noga
- Research Service, Department of Veterans Affairs Medical Center, Miami, FL, USA The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL, USA Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA Department of Physical Medicine and Rehabilitation, Miller School of Medicine, University of Miami, Miami, FL, USA Neuroscience Graduate Program (R50), Miller School of Medicine, University of Miami, Miami, FL, USA Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL, USA; Cruz-Almeida is now with Institute on Aging, Department of Aging and Geriatric Research, College of Medicine, University of Florida, Gainesville, FL, USA
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19
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20
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Interrater reliability of the Korean version of the International Spinal Cord Injury Basic Pain Data Set. Spinal Cord 2014; 52:855-8. [DOI: 10.1038/sc.2014.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 05/27/2014] [Accepted: 05/28/2014] [Indexed: 11/08/2022]
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Avluk OC, Gurcay E, Gurcay AG, Karaahmet OZ, Tamkan U, Cakci A. Effects of chronic pain on function, depression, and sleep among patients with traumatic spinal cord injury. Ann Saudi Med 2014; 34:211-6. [PMID: 25266180 PMCID: PMC6074603 DOI: 10.5144/0256-4947.2014.211] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The main objectives of this cross-sectional study were (1) to examine chronic pain using the Multidimensional Pain Inventory-Spinal Cord Injury (MPI-SCI) version and (2) to assess the relationship between chronic pain and functional status, depression, and sleep quality among patients with SCI. DESIGN AND SETTINGS This was a cross-sectional study of all eligible patients admitted to the Ministry of Health Ankara Diskapi Yildirim Beyazit Education and Research Hospital Physical Therapy and Rehabilitation Clinic between January 2007 and July 2010. METHODS Forty-four patients (33 male, 11 female) with traumatic SCI, aged >=18 years, who had pain continuing for >=6 months and were hospitalized in the physical therapy and rehabilitation clinic were included in this cross-sectional study. Chronic pain intensity, functional status, depression, and sleep quality were assessed according to the MPI-SCI, Functional Independence Measure (FIM), Hamilton Rating Scale for Depression (HAM-D), and Pittsburg Sleep Quality Index (PSQI), respectively. RESULTS A positive correlation was observed between "Pain Severity" (one of the subscales of the MPI-SCI) and HAM-D (r=0.487, P=.001) and PSQI (r=0.312, P=.039). "Pain Severity" was significantly higher in the "impaired sleep" group (P < .05) than in the "normal sleep" group and in the "depression" group (P < .05) than in the "no depression" group. CONCLUSION We identified a strong interrelationship between SCI-related "Pain Severity" and both depression and sleep quality. Hence, a comprehensive pain examination and management strategies including psychosocial interventions should be given particular consideration to address the critical issue of chronic pain in individuals with SCI.
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Affiliation(s)
| | - Eda Gurcay
- Dr. Eda Gurcay, Ministry of Health Ankara,, Diskapi Yildirim Beyazit,, Education and Research Hospital,, Ankara 06010, Turkey, T: +90-312-596-2000 ext. 2993, F: +90-312-318-6690,
| | - Ahmet Gurhan Gurcay
- Dr. Eda Gurcay, Ministry of Health Ankara,, Diskapi Yildirim Beyazit,, Education and Research Hospital,, Ankara 06010, Turkey, T: +90-312-596-2000 ext. 2993, F: +90-312-318-6690,
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22
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Galea MP, Dunlop SA, Davis GM, Nunn A, Geraghty T, Hsueh YSA, Churilov L. Intensive exercise program after spinal cord injury ("Full-On"): study protocol for a randomized controlled trial. Trials 2013; 14:291. [PMID: 24025260 PMCID: PMC3848453 DOI: 10.1186/1745-6215-14-291] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Accepted: 08/27/2013] [Indexed: 11/13/2022] Open
Abstract
Background Rehabilitation after spinal cord injury (SCI) has traditionally involved teaching compensatory strategies for identified impairments and deficits in order to improve functional independence. There is some evidence that regular and intensive activity-based therapies, directed at activation of the paralyzed extremities, promotes neurological improvement. The aim of this study is to compare the effects of a 12-week intensive activity-based therapy program for the whole body with a program of upper body exercise. Methods/Design A multicenter, parallel group, assessor-blinded randomized controlled trial will be conducted. One hundred eighty-eight participants with spinal cord injury, who have completed their primary rehabilitation at least 6 months prior, will be recruited from five SCI units in Australia and New Zealand. Participants will be randomized to an experimental or control group. Experimental participants will receive a 12-week program of intensive exercise for the whole body, including locomotor training, trunk exercises and functional electrical stimulation-assisted cycling. Control participants will receive a 12-week intensive upper body exercise program. The primary outcome is the American Spinal Injuries Association (ASIA) Motor Score. Secondary outcomes include measurements of sensation, function, pain, psychological measures, quality of life and cost effectiveness. All outcomes will be measured at baseline, 12 weeks, 6 months and 12 months by blinded assessors. Recruitment commenced in January 2011. Discussion The results of this trial will determine the effectiveness of a 12-week program of intensive exercise for the whole body in improving neurological recovery after spinal cord injury. Trial registration NCT01236976 (10 November 2010), ACTRN12610000498099 (17 June 2010).
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Affiliation(s)
- Mary P Galea
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC 3010, Australia.
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Burns AS, Delparte JJ, Ballantyne EC, Boschen KA. Evaluation of an interdisciplinary program for chronic pain after spinal cord injury. PM R 2013; 5:832-8. [PMID: 23684779 DOI: 10.1016/j.pmrj.2013.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 04/25/2013] [Accepted: 05/03/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess efficacy of an interdisciplinary pain program adapted for persons with spinal cord injury (SCI) and chronic pain. DESIGN Prospective cohort. SETTING University-affiliated rehabilitation hospital. PARTICIPANTS Twenty-two persons with traumatic or nontraumatic SCI and chronic pain of at least 6 months' duration. METHODS Subjects participated in an interdisciplinary pain program consisting of biweekly group sessions for 10 consecutive weeks. Sessions incorporated patient education on chronic pain and associated pain mechanisms, cognitive behavioral therapy, self-management strategies (eg, energy conservation, ergonomics, goal setting, stress management, anger management, and coping skills), group discussions and activities, and either exercise or guided relaxation at the end of each session. MAIN OUTCOME MEASURES Multidimensional Pain Inventory SCI, Coping Inventory of Stressful Situations, Pain Stages of Change Questionnaire, and Life Satisfaction Questionnaire. RESULTS After participation in an interdisciplinary pain program, persons with SCI and chronic neuropathic pain demonstrated increased involvement in learning and maintenance of coping strategies for chronic pain. Participation also led to less pain interference in daily life and a greater sense of control over one's life. CONCLUSIONS Participation in an interdisciplinary pain program does not reduce pain severity, but it can help persons with SCI and chronic neuropathic pain cope with pain, lessen interference of pain, and improve their sense of control.
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Affiliation(s)
- Anthony S Burns
- Division of Physiatry, Department of Medicine, University of Toronto, and Brain & Spinal Cord Rehabilitation Program, University Health Network-Toronto Rehabilitation Institute, 520 Sutherland Dr, Toronto, Ontario, Canada ON M4G 3V9(∗).
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24
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Psychometric evaluation of the Spanish version of the MPI-SCI. Spinal Cord 2013; 51:538-52. [PMID: 23608807 DOI: 10.1038/sc.2013.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 03/05/2013] [Accepted: 03/07/2013] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Postal surveys. OBJECTIVES To confirm the factor structure of the Spanish version of the MPI-SCI (MPI-SCI-S, Multidimensional Pain Inventory in the SCI population) and to test its internal consistency and construct validity in a Spanish population. SETTING Guttmann Institute, Barcelona, Spain. METHODS The MPI-SCI-S along with Spanish measures of pain intensity (Numerical Rating Scale), pain interference (Brief Pain Inventory), functional independence (Functional Independence Measure), depression (Beck Depression Inventory), locus of control (Multidimensional health Locus of Control), support (Functional Social Support Questionnaire (Duke-UNC)), psychological well-being (Psychological Global Well-Being Index) and demographic/injury characteristics were assessed in persons with spinal cord injury (SCI) and chronic pain (n=126). RESULTS Confirmatory factor analysis suggested an adequate factor structure for the MPI-SCI-S. The internal consistency of the MPI-SCI-S subscales ranged from acceptable (r=0.66, Life Control) to excellent (r=0.94, Life Interference). All MPI-SCI-S subscales showed adequate construct validity, with the exception of the Negative and Solicitous Responses subscales. CONCLUSIONS The Spanish version of the MPI-SCI is adequate for evaluating chronic pain impact following SCI in a Spanish-speaking population. Future studies should include additional measures of pain-related support in the Spanish-speaking SCI population.
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Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Theodore N. Clinical Assessment Following Acute Cervical Spinal Cord Injury. Neurosurgery 2013; 72 Suppl 2:40-53. [DOI: 10.1227/neu.0b013e318276edda] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Beverly C. Walters
- Division of Neurological Surgery
- Department of Neurosciences, Inova Health System, Falls Church, Virginia
| | | | - Sanjay S. Dhall
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Daniel E. Gelb
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - R. John Hurlbert
- Department of Clinical Neurosciences, University of Calgary Spine Program, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Curtis J. Rozzelle
- Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy C. Ryken
- Iowa Spine & Brain Institute, University of Iowa, Waterloo/Iowa City, Iowa
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Widerström-Noga E, Pattany PM, Cruz-Almeida Y, Felix ER, Perez S, Cardenas DD, Martinez-Arizala A. Metabolite concentrations in the anterior cingulate cortex predict high neuropathic pain impact after spinal cord injury. Pain 2012; 154:204-212. [PMID: 23141478 DOI: 10.1016/j.pain.2012.07.022] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 07/13/2012] [Accepted: 07/20/2012] [Indexed: 12/24/2022]
Abstract
Persistent pain is a common reason for reduced quality of life after a spinal cord injury (SCI). Biomarkers of neuropathic pain may facilitate translational research and the understanding of underlying mechanisms. Research suggests that pain and affective distress are anatomically and functionally integrated in the anterior cingulate cortex and can modulate sensory and affective aspects of pain. We hypothesized that severe neuropathic pain with a significant psychosocial impact would be associated with metabolite concentrations (obtained by magnetic resonance spectroscopy) in the anterior cingulate cortex, indicating neuronal and/or glial dysfunction. Participants with SCI and severe, high-impact neuropathic pain (SCI-HPI; n=16), SCI and moderate, low-impact neuropathic pain (SCI-LPI; n=24), SCI without neuropathic pain (SCI-noNP; n=14), and able-bodied, pain-free control subjects (A-B; n=22) underwent a 3-T magnetic resonance imaging brain scan. Analyses revealed that the SCI-HPI group had significantly higher levels of myoinositol (Ins) (P<.000), creatine (P=.007), and choline (P=.014), and significantly lower levels of N-acetyl aspartate/Ins (P=.024) and glutamate-glutamine (Glx)/Ins (P=.003) ratios than the SCI-LPI group. The lower Glx/Ins ratio significantly discriminated between SCI-HPI and the A-B (P=.006) and SCI-noNP (P=.026) groups, displayed excellent test-retest reliability, and was significantly related to greater pain severity, interference, and affective distress. This suggests that the combination of lower glutamatergic metabolism and proliferation of glia and glial activation are underlying mechanisms contributing to the maintenance of severe neuropathic pain with significant psychosocial impact in chronic SCI. These findings indicate that the Glx/Ins ratio may be a useful biomarker for severe SCI-related neuropathic pain with significant psychosocial impact.
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Affiliation(s)
- Eva Widerström-Noga
- Research Service, Department of Veterans Affairs Medical Center, Miami, FL, USA The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL, USA Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA Department of Rehabilitation Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA Neuroscience Graduate Program, Miller School of Medicine, University of Miami, Miami, FL, USA Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL, USA Spinal Cord Injury Service, Department of Veterans Affairs Medical Center, Miami, FL, USA
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Taylor J, Huelbes S, Albu S, Gómez-Soriano J, Peñacoba C, Poole HM. Neuropathic Pain Intensity, Unpleasantness, Coping Strategies, and Psychosocial Factors after Spinal Cord Injury: An Exploratory Longitudinal Study During the First Year. PAIN MEDICINE 2012; 13:1457-68. [DOI: 10.1111/j.1526-4637.2012.01483.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cruz-Almeida Y, Felix ER, Martinez-Arizala A, Widerström-Noga EG. Decreased spinothalamic and dorsal column medial lemniscus-mediated function is associated with neuropathic pain after spinal cord injury. J Neurotrauma 2012; 29:2706-15. [PMID: 22845918 DOI: 10.1089/neu.2012.2343] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Neuropathic pain (NP) after spinal cord injury (SCI) can significantly and negatively affect quality of life and is often refractory to currently available treatments. In order to find more effective therapeutic avenues, it would be helpful to identify the primary underlying pathophysiological mechanisms in each individual. The aim of the present study was to assess the relationship between the presence and severity of NP after SCI and measures of somatosensory function mediated via the dorsal column medial lemniscal (DCML) pathway and the spinothalamic tract (STT). Vibratory, mechanical, thermal, and pain thresholds measured in areas at and below the neurological level of injury (LOI) in persons with SCI and NP (SCI-NP, n=47) and in persons with SCI without NP (SCI-noNP, n=18) were normalized to data obtained from able-bodied pain-free control subjects (A-B, n=30). STT-mediated function at and below the LOI was significantly impaired in both SCI groups compared with A-B controls (p<0.001), but not significantly different between the two SCI groups (NP vs. no-NP). In contrast, the SCI-NP group had significantly greater impairment of DCML-mediated function at the LOI, as reflected by greater vibratory detection deficits (z=-3.89±0.5), compared with the SCI-noNP group (z=-1.95±0.7, p=0.034). Within the SCI-NP group, NP severity was significantly associated with increased thermal sensitivity below the LOI (r=0.50, p=0.038). Our results suggest that both impaired STT and DCML-mediated function are necessary for the development of NP after SCI. However, within the SCI-NP group, greater NP severity was associated with greater sensitivity to thermal stimuli below the LOI. This finding concurs with other studies suggesting that STT damage with some sparing is associated with NP.
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Affiliation(s)
- Yenisel Cruz-Almeida
- Research Service, Department of Veterans Affairs Medical Center, Miami, Florida, USA
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Furlan JC, Noonan V, Singh A, Fehlings MG. Assessment of impairment in patients with acute traumatic spinal cord injury: a systematic review of the literature. J Neurotrauma 2011; 28:1445-77. [PMID: 20030559 PMCID: PMC3143408 DOI: 10.1089/neu.2009.1152] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The most common primary end-point of the trial on treatment of traumatic spinal cord injury (SCI) is the degree of impairment. The American Spinal Injury Association (ASIA) Standards have been widely used to assess motor function and pin-prick and light-touch sensory function. In addition, pain assessment is another clinically relevant aspect of the impairment in individuals with SCI. Given this, we sought to systematically review the studies that focused on the psychometric properties of ASIA Standards and all previously used outcome measures of pain in the SCI population in the acute care setting. For the primary literature search strategy, the MEDLINE, CINAHL, EMBASE, and Cochrane databases were sought out. Subsequently, a secondary search strategy was carried out using the articles listed in the references of meta-analysis, systematic, and non-systematic review articles. Two reviewers (JCF and VN) independently selected the articles that fulfill the inclusion and exclusion, assessed the level of evidence of each article, and appraised the psychometric properties of each instrument. Divergences during those steps were solved by consensus between both reviewers. Of 400 abstracts captured in our primary search strategy on the ASIA Standards, 16 full articles fulfilled the inclusion and exclusion criteria. An additional 40 references were obtained from two prior systematic reviews on ASIA Standards. While 45 of 56 of the studies on ASIA Standards provided level 4 evidence, there were 11 level 2b evidence studies. Convergent construct validity (n = 34), reliability (n = 12), and responsiveness (n = 10) were the most commonly studied psychometric properties of the ASIA Standards, but two prior studies examined their content validity. Of the 267 abstracts yielded in our primary search on pain assessment, 24 articles with level 4 evidence fulfilled the inclusion and exclusion criteria. There was no study that examined pain assessment in the acute care setting. While 18 of 24 articles studied an instrument for assessment of pain intensity, the remaining six studies were focused on classifications of pain in the SCI population. In conclusion, the ASIA Standards represent an appropriate instrument to categorize and evaluate spinal cord injured adults over time with respect to their motor and sensory function. Nevertheless, further investigation of the psychometric properties of the ASIA Standards is recommended due to a lack of studies focused on some key elements of responsiveness, including minimal clinically important difference. The visual analog scale (VAS) is the most commonly studied instrument of assessment of pain intensity in the SCI population. However, further investigation is required with regard to its reliability and responsiveness in the SCI population. Our results also suggest that there is no instrument with appropriate psychometric properties for this particular population.
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Affiliation(s)
- Julio C. Furlan
- Department of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Vanessa Noonan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Anoushka Singh
- Department of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Department of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Division of Neurosurgery and Spinal Program University of Toronto, Toronto, Ontario, Canada
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Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. Arch Phys Med Rehabil 2011; 92:146-60. [PMID: 21187217 PMCID: PMC3028590 DOI: 10.1016/j.apmr.2010.09.021] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 08/21/2010] [Accepted: 09/16/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To systematically review the research findings regarding the associations between psychosocial factors and adjustment to chronic pain in persons with physical disabilities. DATA SOURCES A key word literature search was conducted using articles listed in PubMed, PsychInfo, and CINAHL up to March 2010, and manual searches were made of all retrieved articles to identify published articles that met the review inclusion criteria. STUDY SELECTION To be included in the review, articles needed to (1) be written in English, (2) include adults with a physical disability who report having pain, (3) include at least 1 measure of a psychosocial predictor domain, (4) include at least 1 criterion measure of pain or patient functioning, and (5) report the results of associations between the psychosocial factors and criterion measures used in the study. Twenty-nine studies met the inclusion criteria. DATA EXTRACTION Three reviewers tabulated study details and findings. DATA SYNTHESIS The disability groups studied included spinal cord injury (SCI), acquired amputation, cerebral palsy (CP), multiple sclerosis (MS), and muscular dystrophy (MD). Psychosocial factors were shown to be significantly associated with pain and dysfunction in all disability groups. The psychosocial factors most closely associated with pain and dysfunction across the samples included (1) catastrophizing cognitions; (2) task persistence, guarding, and resting coping responses; and (3) perceived social support and solicitous responding social factors. Pain-related beliefs were more strongly associated with pain and dysfunction in the SCI, CP, MS, and MD groups than in the acquired amputation group. CONCLUSIONS The findings support the importance of psychosocial factors as significant predictors of pain and functioning in persons with physical disabilities. Clinical trials to test the efficacy of psychosocial treatments for pain and dysfunction are warranted, as are studies to determine whether psychosocial factors have a causal influence on pain and adjustment in these populations.
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Affiliation(s)
- Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, USA.
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Widerström-Noga E, Finlayson ML. Aging with a Disability: Physical Impairment, Pain, and Fatigue. Phys Med Rehabil Clin N Am 2010; 21:321-37. [DOI: 10.1016/j.pmr.2009.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Comparison of a Pain Management Program With Usual Care in a Pain Management Center for People With Spinal Cord Injury-related Chronic Pain. Clin J Pain 2010; 26:206-16. [DOI: 10.1097/ajp.0b013e3181bff8f3] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cruz-Almeida Y, Felix ER, Martinez-Arizala A, Widerström-Noga EG. Pain symptom profiles in persons with spinal cord injury. PAIN MEDICINE 2010; 10:1246-59. [PMID: 19818035 DOI: 10.1111/j.1526-4637.2009.00713.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Persistent pain is a common consequence of spinal cord injury. A patient-specific assessment that combines both the identification of pain symptoms and psychosocial factors is needed for a tailored treatment approach. The aim of the study was to define pain symptom profiles and to determine their relationship with psychosocial factors in persons with spinal cord injury. DESIGN Face-to-face interview and examination. SETTING VA Medical Center and Miami Project to Cure Paralysis, Miami, Florida. PATIENTS Persons with spinal cord injury (135 men and 21 women) provided detailed descriptions of 330 neuropathic pains. OUTCOME MEASURES The American Spinal Injury Impairment Scale, pain history and measures of pain interference, life satisfaction, locus of control, social support and depression. RESULTS The exploratory factor analyses and regression analyses revealed three distinct symptom profiles: 1) aching, throbbing pain, aggravated by cold weather and constipation predicted by a combination of chance locus of control and lower levels of life satisfaction; 2) stabbing, penetrating, and constant pain of high intensity predicted by a combination of pain interference, localized pain, powerful others locus of control and depressed mood; and 3) burning, electric, and stinging pain aggravated by touch and muscle spasms predicted by pain interference. CONCLUSIONS Although these results need to be replicated in other spinal cord injury samples, our findings suggest that pain symptom profiles may be a useful way to further characterize pain in a comprehensive assessment strategy.
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Affiliation(s)
- Yenisel Cruz-Almeida
- Department of Veterans Affairs Medical Center, University of Miami Miller School of Medicine, Miami, FL 33101, USA
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Cardenas DD, Felix ER. Pain after Spinal Cord Injury: A Review of Classification, Treatment Approaches, and Treatment Assessment. PM R 2009; 1:1077-90. [DOI: 10.1016/j.pmrj.2009.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 06/29/2009] [Accepted: 07/07/2009] [Indexed: 10/20/2022]
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Jensen MP, Widerström-Noga E, Richards JS, Finnerup NB, Biering-Sørensen F, Cardenas DD. Reliability and validity of the International Spinal Cord Injury Basic Pain Data Set items as self-report measures. Spinal Cord 2009; 48:230-8. [PMID: 19786975 PMCID: PMC2832715 DOI: 10.1038/sc.2009.112] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective To evaluate the psychometric properties of a subset of International Spinal Cord Injury Basic Pain Data Set (ISCIBPDS) items that could be used as self-report measures in surveys, longitudinal studies and clinical trials. Setting Community. Methods A subset of the ISCIBPDS items and measures of two validity criteria were administered in a postal survey to 184 individuals with spinal cord injury (SCI) and pain. The responses of the participants were evaluated to determine: (1) item response rates (as an estimate of ease of item completion); (2) internal consistency (as an estimate of the reliability of the multiple-item measures); and (3) concurrent validity. Results The results support the utility and validity of the ISCIBPDS items and scales that measure pain interference, intensity, site(s), frequency, duration, and timing (time of day of worst pain) in individuals with SCI and chronic pain. The results also provide psychometric information that can be used to select from among the ISCIBPDS items in settings that require even fewer items than are in the basic dataset.
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Affiliation(s)
- M P Jensen
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA 98195-6490, USA.
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Alexander MS, Anderson KD, Biering-Sorensen F, Blight AR, Brannon R, Bryce TN, Creasey G, Catz A, Curt A, Donovan W, Ditunno J, Ellaway P, Finnerup NB, Graves DE, Haynes BA, Heinemann AW, Jackson AB, Johnston MV, Kalpakjian CZ, Kleitman N, Krassioukov A, Krogh K, Lammertse D, Magasi S, Mulcahey MJ, Schurch B, Sherwood A, Steeves JD, Stiens S, Tulsky DS, van Hedel HJA, Whiteneck G. Outcome measures in spinal cord injury: recent assessments and recommendations for future directions. Spinal Cord 2009; 47:582-91. [PMID: 19381157 PMCID: PMC2722687 DOI: 10.1038/sc.2009.18] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Review by the spinal cord outcomes partnership endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations. OBJECTIVES Assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies. METHODS a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI. RESULTS Imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain and psychosocial tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention. CONCLUSION Significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.
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Neuropathic pain in spinal cord injury: identification, classification, evaluation. Ann Phys Rehabil Med 2009; 52:83-102. [PMID: 19909700 DOI: 10.1016/j.rehab.2008.12.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 12/17/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Chronic pain is very frequent after spinal cord injury, recent data showing that at least 80% of the patients experience pain, one-third at a severe level. The main objective of the present work is to report and discuss data regarding tools and procedures for the screening, diagnosis, and evaluation of neuropathic pain in spinal cord injury patients. MATERIAL AND METHOD The method used is that developed by the SOFMER, which associated a systematic review of the literature and a selection of published works by a scientific commitee, an analysis of data performed by a binom neuropathic pain/physical medicine and rehabilitation (PM&R) specialists, an evaluation of current practices during an expert consensus conference and via Internet, and finally a validation of the whole work by a pluridisciplinary expert panel. RESULTS The literature provides an important series of studies on pain in spinal injury, but without specific data about neuropathic pain in this population. Some specific diagnostic and evaluation tools for neuropathic pain have been developed these last years, while numerous classifications, based on various criteria, have been proposed, some of them exhibiting some advantages for a pragmatic application and being in parallel in accordance with recent nosological and physiopathological advances. DISCUSSION The DN4 questionnaire can be used for the screening and identification of neuropathic pain in this population of patients, often suffering from various types of pain. The use of the Spinal Cord Injury Pain Task Force of the International Association of the Study of Pain classification (SCIP-IASP), although some limitations, is recommended since taking into account physiopathology, localisation, and nature of pain. Daily uses of Visual Analogic Scale (VAS) or Numeric Scale (NS) are an obvious need and that of the questionnaire Douleur de Saint-Antoine (QDSA) for global evaluation and more specifically of the Neuropathic Pain Symptom Inventory (NPSI) for neuropathic pain are highly recommended.
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Differentiation between pain-related interference and interference caused by the functional impairments of spinal cord injury. Spinal Cord 2008; 47:390-5. [DOI: 10.1038/sc.2008.150] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hoschouer EL, Yin FQ, Jakeman LB. L1 cell adhesion molecule is essential for the maintenance of hyperalgesia after spinal cord injury. Exp Neurol 2008; 216:22-34. [PMID: 19059398 DOI: 10.1016/j.expneurol.2008.10.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 10/21/2008] [Accepted: 10/31/2008] [Indexed: 10/21/2022]
Abstract
Spinal cord injury (SCI) results in a loss of normal motor and sensory function, leading to severe disability and reduced quality of life. A large proportion of individuals with SCI also suffer from neuropathic pain symptoms. The causes of abnormal pain sensations are not well understood, but can include aberrant sprouting and reorganization of injured or spared sensory afferent fibers. L1 is a cell adhesion molecule that contributes to axonal outgrowth, guidance and fasciculation in development as well as synapse formation and plasticity throughout life. In the present study, we used L1 knockout (KO) mice to determine whether this adhesion molecule contributes to sensory dysfunction after SCI. Both wild-type (WT) and KO mice developed heat hyperalgesia following contusion injury, but the KO mice recovered normal response latencies beginning at 4 weeks post-injury. Histological analyses confirmed increased sprouting of sensory fibers containing calcitonin-gene related peptide (CGRP) in the deep dorsal horn of the lumbar spinal cord and increased numbers of interneurons expressing protein kinase C gamma (PKCgamma) in WT mice 6 weeks after injury. In contrast, L1 KO mice had less CGRP(+) fiber sprouting, but even greater numbers of PKCgamma(+) interneurons at the 6 week time point. These data demonstrate that L1 plays a role in maintenance of thermal hyperalgesia after SCI in mice, and implicate CGRP(+) fiber sprouting and the upregulation of PKCgamma expression as potential contributors to this response.
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Affiliation(s)
- Emily L Hoschouer
- Department of Physiology and Cell Biology, The Ohio State University Medical Center, Columbus, OH, USA
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Silvemark AJ, Källmén H, Portala K, Molander C. Life satisfaction in patients with long-term non-malignant pain - relating LiSat-11 to the Multidimensional Pain Inventory (MPI). Health Qual Life Outcomes 2008; 6:70. [PMID: 18811930 PMCID: PMC2564919 DOI: 10.1186/1477-7525-6-70] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2007] [Accepted: 09/23/2008] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The West-Haven Multidimensional Pain Inventory (MPI) can be used to describe behavioural and psychosocial consequences of long-term pain but little is known about how MPI items and MPI subgroups relate to goals that patients find important in rehabilitation. Life satisfaction measured by the LiSat-11 checklist can be defined as an individual's perception of the difference between his reality and his needs or wants. This difference can be considered a "goal achievement gap". This study investigates the relation of MPI to LiSat-11 with the aim to explore the possibility that LiSat-11 can be used to measure pain rehabilitation outcomes that are important from the patients' view. METHODS Participators were patients (n = 294) referred to the Pain and Rehabilitation Clinic in Uppsala, Sweden. Measures used were LiSat-11, MPI and its Swedish version MPI-S. LiSat-11 domains were correlated to MPI scales. Cluster analysis was used to demonstrate MPI-S subgroups. Analysis of variance followed by post-hoc analysis was used to investigate life satisfaction in the three MPI-S subgroups. RESULTS The strongest positive correlation were found for the LiSat-11 domains/MPI scales: psychological health/life control and contacts/social activities, and the strongest negative correlation for: psychological health/affective distress, partner relationship/punishing responses, somatic health/interference and leisure/interference. None or only little correlation was found between MPI scale pain severity and most LiSat-11 domains and satisfaction with life as a whole. Among the MPI-S subgroups, adaptive copers generally had better life satisfaction than the dysfunctional and the interpersonally distressed. CONCLUSION Pain severity alone is a rather poor predictor of low life satisfaction. MPI and LiSat-11 partly supplement each other as tools to describe how functional impairments relate to life satisfaction domains, which may be relevant for identifying domains which the patients find important to improve. Furthermore, differences in life satisfaction between the MPI-S subgroups may help to identify functional domains that may be of particular importance in specialised rehabilitation programs.
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Affiliation(s)
- Annika J Silvemark
- Department of Neuroscience, Rehabilitation Medicine, Uppsala University, Uppsala University Hospital, SE-751 85 Uppsala, Sweden.
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Spinal cord injury-related pain in rehabilitation: a cross-sectional study of relationships with cognitions, mood and physical function. Eur J Pain 2008; 13:511-7. [PMID: 18653364 DOI: 10.1016/j.ejpain.2008.06.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 05/22/2008] [Accepted: 06/07/2008] [Indexed: 11/23/2022]
Abstract
Although psychological aspects of SCI-related pain have been investigated in those with chronic pain, little data is available regarding these factors in those early in the course of the injury. Using a sample admitted for SCI rehabilitation, this paper describes the relationships between usual pain intensity, mood, disability and both pain and SCI-related psychological factors. The sample were largely similar to other samples of individuals with SCI-related chronic pain in terms of mood, but were noted to be less catastrophic in their thinking about pain than a comparative pain clinic sample. They also reported SCI self-efficacy and acceptance scores consistent with other SCI samples. Compared with other SCI populations there were mixed findings in relation to physical disability. Consistent with previous findings in chronic pain SCI samples, usual pain intensity was found to have a strong relationship with symptoms of anxiety and depression, and pain-related life interference. SCI acceptance was significantly negatively associated with depression scores, pain catastrophizing was significantly positively associated with both anxiety and depression scores, and SCI self-efficacy was significantly negatively associated with both anxiety and depression scores. SCI self-efficacy was also significantly positively associated with physical function scores. These findings suggest that pain-related psychological factors may have importance even early in the clinical course following SCI, but that it is important, however, to consider more general SCI-related psychological factors alongside them. In addition, these findings suggest the possibility that early interventions based upon the cognitive behavioural treatment of pain may be integrated into SCI rehabilitation programmes.
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Psychosocial Subgroups in Persons With Spinal Cord Injuries and Chronic Pain. Arch Phys Med Rehabil 2007; 88:1628-35. [DOI: 10.1016/j.apmr.2007.09.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Widerström-Noga E, Cardenas D. The Role of Brain Imaging in SCI-Related Pain. Top Spinal Cord Inj Rehabil 2007. [DOI: 10.1310/sci1302-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Pain is one of the most common, severe, and treatment-resistant complications that follows SCI. Recent years have seen a surge of research on methods for assessing and treating spinal cord injury pain. In this article, pain after SCI is reviewed in terms of nature, scope, assessment techniques, and treatment strategies.
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Affiliation(s)
- Philip M Ullrich
- Veterans Affairs Puget Sound Healthcare System, SCI/D Services (128NAT), 1660 S. Columbian Way, Seattle, WA 98108, USA.
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Finnerup NB, Sindrup SH, Jensen TS. Chronic neuropathic pain: mechanisms, drug targets and measurement. Fundam Clin Pharmacol 2007; 21:129-36. [PMID: 17391285 DOI: 10.1111/j.1472-8206.2007.00474.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neuropathic pain is common in many diseases or injuries of the peripheral or central nervous system, and has a substantial impact on quality of life and mood. Lesions of the nervous system may lead to potentially irreversible changes and imbalance between excitatory and inhibitory systems. Preclinical research provides several promising targets for treatment such as sodium and calcium channels, glutamate receptors, monoamines and neurotrophic factors; however, treatment is often insufficient. A mechanism-based treatment approach is suggested to improve treatment. Valid and reliable tools to assess various symptoms and signs in neuropathic pain and knowledge of drug mechanisms are prerequisites for pursuing this approach. The present review summarizes mechanisms of neuropathic pain, targets of currently used drugs, and measures used in neuropathic pain trials.
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Affiliation(s)
- Nanna B Finnerup
- Department of Neurology, Danish Pain Research Center, Aarhus University Hospital, DK-8000 Aarhus, Denmark.
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Bryce TN, Budh CN, Cardenas DD, Dijkers M, Felix ER, Finnerup NB, Kennedy P, Lundeberg T, Richards JS, Rintala DH, Siddall P, Widerstrom-Noga E. Pain after spinal cord injury: an evidence-based review for clinical practice and research. Report of the National Institute on Disability and Rehabilitation Research Spinal Cord Injury Measures meeting. J Spinal Cord Med 2007; 30:421-40. [PMID: 18092558 PMCID: PMC2141724 DOI: 10.1080/10790268.2007.11753405] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND/OBJECTIVES To examine the reliability, validity, sensitivity, and practicality of various outcome measures for pain after spinal cord injury (SCI), and to provide recommendations for specific measures for use in clinical trials. DATA SOURCES Relevant articles were obtained through a search of MEDLINE, EMBASE, CINAHL, and PubMed databases from inception through 2006. STUDY SELECTION The authors performed literature searches to find articles containing data relevant to the reliability and validity of each pain outcome measure in SCI and selected non-SCI populations. DATA EXTRACTION After reviewing the articles, an investigator extracted information utilizing a standard template. A second investigator reviewed the chosen articles and the extracted pertinent information to confirm the findings of the first investigator. DATA SYNTHESIS Taking into consideration both the quantity and quality of the studies analyzed, judgments on reliability and validity of the measures were made by the two investigators. Based upon these judgments, recommendations were formulated for use of specific measures in future clinical trials. In addition, for a subset of measures a voting process by a larger group of SCI experts allowed formulation of recommendations including determining which measures should be incorporated into a minimal dataset of measures for clinical trials and which ones need revision and further validity and reliability testing before use. CONCLUSIONS A 0-10 Point Numerical Rating Scale (NRS) is recommended as the outcome measure for pain intensity after SCI, while the 7-Point Guy/Farrar Patient Global Impression of Change (PGIC) scale is recommended as the outcome measure for global improvement in pain. The SF-36 single pain interference question and the Multidimensional Pain Inventory (MPI) or Brief Pain Inventory (BPI) pain interference items are recommended as the outcome measures for pain interference after SCI. Brush or cotton wool and at least one high-threshold von Frey filament are recommended to test mechanical allodynia/hyperalgesia while a Peltier-type thermotester is recommended to test thermal allodynia/hyperalgesia. The International Association for the Study of Pain (IASP) or Bryce-Ragnarsson pain taxonomies are recommended for classification of pain after SCI, while the Neuropathic Pain Scale (NPS) is recommended for measuring change in neuropathic pain and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) for quantitating neuropathic and nociceptive pain discrimination.
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Affiliation(s)
- Thomas N Bryce
- Please address correspondence to Thomas N. Bryce, MD, Department of Rehabilitation Medicine, The Mount Sinai Medical Center, 5 East 98th Street, 6th floor, Box 1240B, New York, NY 10021; phone 212.241.6321; fax: 212.369.6389 (e-mail: )
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Laser literature watch. Photomed Laser Surg 2006; 24:537-71. [PMID: 16942439 DOI: 10.1089/pho.2006.24.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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