Pain after Spinal Cord Injury: A Review of Classification, Treatment Approaches, and Treatment Assessment

Combining clinically common drugs with hindlimb stretching in spinal cord injured rodents

STUDY DESIGN

Preclinical pilot study.

OBJECTIVES

To explore peripheral and central nociceptive mechanisms that contribute to muscle stretch-induced locomotor deficits following spinal cord injury.

SETTING

Kentucky Spinal Cord Injury Research Center, Louisville, KY, USA.

METHODS

Ten female Sprague-Dawley rats received moderate, 25 g/cm T10 contusion injuries and recovered for 4 weeks. Rats were divided into three groups: Morphine/Ibuprofen-treated, Acetaminophen/Baclofen-treated, and saline control. Each group received daily hindlimb muscle stretching during weeks 4, 5, 9, and 10 post-injury and drugs were administered with stretching during weeks 4 and 9 only. Locomotor function was assessed throughout the experiment using the BBB Open Field Locomotor Scale. Hindlimb responses including spasticity, writhing, and clonic-like vibrations during muscle stretching were classified and scored.

RESULTS

Consistent with our previous studies, hindlimb muscle stretching caused significant deficits in locomotor recovery following spinal cord injury. Baclofen and Ibuprofen partially mitigated the stretching effect, but none of the drugs significantly prevented the drop in locomotor function during stretching. Interestingly, treatment with Baclofen or Ibuprofen significantly reduced hindlimb responses such as spasticity and writhing during stretching, while Morphine exacerbated clonic-like vibrations in response to stretching maneuvers.

CONCLUSIONS

These findings suggest that stretching may inhibit locomotor recovery through combined mechanisms of peripheral inflammation and sensitization of nociceptive afferents. When combined with central sprouting and loss of descending controls after SCI, this results in exaggerated nociceptive input during stretching. The inability of the applied clinical drugs to mitigate the detrimental effects of stretching highlights the complexity of the stretching phenomenon and emphasizes the need for further investigation.

Mechanical diagnosis and therapy in musculoskeletal pain of individuals with spinal cord injury

CONTEXT/OBJECTIVE

Musculoskeletal pain (MSKP) has high prevalence in individuals with spinal cord injury (SCI). Mechanical Diagnosis and Therapy (MDT) is a method focused on identifying the pain source in the musculoskeletal system and presents good results in pain relief in people without neurological impairment. However, no studies have investigated the use of MDT in SCI population. The objective was to evaluate the applicability and outcomes of MDT treatment in pain relief and independence improvement in daily activities of individuals with SCI presenting MSKP.

DESIGN

Single-arm trial.

SETTING

Rehabilitation Hospital.

PARTICIPANTS

Twenty-four individuals with SCI who presented MSKP.

INTERVENTION

MDT-certified physical therapist conducted assessments and treatments of pain according to the MDT approach.

OUTCOMES MEASURES

Numeric rating scale (NRS) was used to measure pain and Pain Disability Index (PDI) and Patient-Specific Functional Scale (PSFS) to evaluate daily activities.

RESULTS

Significant median decreases were found for NRS (from 7 to 2) and PDI (from 27 to 8) after MDT, whereas PSFS score presented a significant mean increase (from 3.2-7.7). The average decrease in pain after MDT treatment was 70.9% (5.36 on the NRS).

CONCLUSION

MDT can reduce pain and enhance independence in daily activities in individuals with SCI and MSKP.

Exploring the Experience of Living with Pain after Spinal Cord Injury: A Qualitative Study

A spinal cord injury is a life-changing experience that results in functional limitations and an increased risk of secondary health conditions. People with spinal cord injury identify pain as the most devastating health problem following their injury that not only affects their social life but their mental well-being as well. This study is aimed at exploring the lived experience of living with pain by community-dwelling manual wheelchair users with spinal cord injuries. An explorative qualitative design was used to explore their experiences. In-depth interviews were recorded and transcribed, and the data were analysed using inductive thematic content analysis in the MAXQDA v2020. Fifteen manual wheelchair users with paraplegia participated in this study, and four themes were identified from their experience of living with pain: pain constantly lurks, pain is worse than the direct consequences of the SCI, pain is restrictive, and life continues despite the pain. Categories and subcategories included the participants being one with the pain; pain interfering with sleep; feelings of anger, isolation, and suicidal ideation; and uncertainties about what the future holds living with pain. Living with pain after SCI is a challenging feat, and effective management of pain is necessary to improve not only functioning and mobility but also mental health and life satisfaction.

Development of a pain self-management intervention framework for people with spinal cord injury

BACKGROUND

 Pain is the most common reason for medical visits to primary health care practitioners. Pain self-management interventions are encouraged and there is no known self-management intervention framework available that clinicians and people with spinal cord injury (PWSCI) can use to guide treatment selection.

AIM

 This study aimed to develop a pain self-management intervention framework for PWSCI.

SETTING

 Online and facilitated in Gauteng, South Africa.

METHODS

 A three-round modified e-Delphi method was used to reach an 80% consensus among a 21-expert panel. Fifty-nine interventions were distributed via REDCap and a final online audio meeting was held to either include or exclude interventions in the final framework. SPSS v27 was used to analyse descriptive data and content analysis was used for qualitative responses.

RESULTS

 The final developed pain self-management framework consists of 56 interventions and includes interventions from multiple health professions to encompass medical, psychological, therapeutic and social interventions. Interventions are also specified for nociceptive and/or neuropathic pain and grouped according to the biopsychosocial model.

CONCLUSION

 The interprofessional framework may be used as a guideline for PWSCI to alleviate pain, as well as assist health professionals in clinical decision-making, by providing them with the freedom to choose acceptable and adequate interventions that may be appropriate to treat the affected individual's pain.Contribution: Pain management is a basic need at the primary healthcare level and PWSCI need access to the broad range of interventions available to manage their pain. The framework highlights the variety of appropriate interventions to guide both health professionals and PWSCI with pain relief options.

Non-Coding RNAs Regulate Spinal Cord Injury-Related Neuropathic Pain via Neuroinflammation

Secondary chronic neuropathic pain (NP) in addition to sensory, motor, or autonomic dysfunction can significantly reduce quality of life after spinal cord injury (SCI). The mechanisms of SCI-related NP have been studied in clinical trials and with the use of experimental models. However, in developing new treatment strategies for SCI patients, NP poses new challenges. The inflammatory response following SCI promotes the development of NP. Previous studies suggest that reducing neuroinflammation following SCI can improve NP-related behaviors. Intensive studies of the roles of non-coding RNAs in SCI have discovered that ncRNAs bind target mRNA, act between activated glia, neuronal cells, or other immunocytes, regulate gene expression, inhibit inflammation, and influence the prognosis of NP.

Resting state functional connectivity differentiation of neuropathic and nociceptive pain in individuals with chronic spinal cord injury

Many individuals with spinal cord injury live with debilitating chronic pain that may be neuropathic, nociceptive, or a combination of both in nature. Identification of brain regions demonstrating altered connectivity associated with the type and severity of pain experience may elucidate underlying mechanisms, as well as treatment targets. Resting state and sensorimotor task-based magnetic resonance imaging data were collected in 37 individuals with chronic spinal cord injury. Seed-based correlations were utilized to identify resting state functional connectivity of regions with established roles in pain processing: the primary motor and somatosensory cortices, cingulate, insula, hippocampus, parahippocampal gyri, thalamus, amygdala, caudate, putamen, and periaqueductal gray matter. Resting state functional connectivity alterations and task-based activation associated with individuals' pain type and intensity ratings on the International Spinal Cord Injury Basic Pain Dataset (0-10 scale) were evaluated. We found that intralimbic and limbostriatal resting state connectivity alterations are uniquely associated with neuropathic pain severity, whereas thalamocortical and thalamolimbic connectivity alterations are associated specifically with nociceptive pain severity. The joint effect and contrast of both pain types were associated with altered limbocortical connectivity. No significant differences in task-based activation were identified. These findings suggest that the experience of pain in individuals with spinal cord injury may be associated with unique alterations in resting state functional connectivity dependent upon pain type.

Combined non-psychoactive Cannabis components cannabidiol and β-caryophyllene reduce chronic pain via CB1 interaction in a rat spinal cord injury model

The most frequently reported use of medical marijuana is for pain relief. However, its psychoactive component Δ9-tetrahydrocannabinol (THC) causes significant side effects. Cannabidiol (CBD) and β-caryophyllene (BCP), two other cannabis constituents, possess more benign side effect profiles and are also reported to reduce neuropathic and inflammatory pain. We evaluated the analgesic potential of CBD and BCP individually and in combination in a rat spinal cord injury (SCI) clip compression chronic pain model. Individually, both phytocannabinoids produced dose-dependent reduction in tactile and cold hypersensitivity in male and female rats with SCI. When co-administered at fixed ratios based on individual A50s, CBD and BCP produced enhanced dose-dependent reduction in allodynic responses with synergistic effects observed for cold hypersensitivity in both sexes and additive effects for tactile hypersensitivity in males. Antinociceptive effects of both individual and combined treatment were generally less robust in females than males. CBD:BCP co-administration also partially reduced morphine-seeking behavior in a conditioned place preference (CPP) test. Minimal cannabinoidergic side effects were observed with high doses of the combination. The antinociceptive effects of the CBD:BCP co-administration were not altered by either CB2 or μ-opioid receptor antagonist pretreatment but, were nearly completely blocked by CB1 antagonist AM251. Since neither CBD or BCP are thought to mediate antinociception via CB1 activity, these findings suggest a novel CB1 interactive mechanism between these two phytocannabinoids in the SCI pain state. Together, these findings suggest that CBD:BCP co-administration may provide a safe and effective treatment option for the management of chronic SCI pain.

Pharmacological and non-pharmacological therapeutic interventions for the treatment of spinal cord injury-induced pain

Spinal cord injury (SCI) is a complex neurophysiological disorder, which can result in many long-term complications including changes in mobility, bowel and bladder function, cardiovascular function, and metabolism. In addition, most individuals with SCI experience some form of chronic pain, with one-third of these individuals rating their pain as severe and unrelenting. SCI-induced chronic pain is considered to be "high impact" and broadly affects a number of outcome measures, including daily activity, physical and cognitive function, mood, sleep, and overall quality of life. The majority of SCI pain patients suffer from pain that emanates from regions located below the level of injury. This pain is often rated as the most severe and the underlying mechanisms involve injury-induced plasticity along the entire neuraxis and within the peripheral nervous system. Unfortunately, current therapies for SCI-induced chronic pain lack universal efficacy. Pharmacological treatments, such as opioids, anticonvulsants, and antidepressants, have been shown to have limited success in promoting pain relief. In addition, these treatments are accompanied by many adverse events and safety issues that compound existing functional deficits in the spinally injured, such as gastrointestinal motility and respiration. Non-pharmacological treatments are safer alternatives that can be specifically tailored to the individual and used in tandem with pharmacological therapies if needed. This review describes existing non-pharmacological therapies that have been used to treat SCI-induced pain in both preclinical models and clinical populations. These include physical (i.e., exercise, acupuncture, and hyper- or hypothermia treatments), psychological (i.e., meditation and cognitive behavioral therapy), and dietary interventions (i.e., ketogenic and anti-inflammatory diet). Findings on the effectiveness of these interventions in reducing SCI-induced pain and improving quality of life are discussed. Overall, although studies suggest non-pharmacological treatments could be beneficial in reducing SCI-induced chronic pain, further research is needed. Additionally, because chronic pain, including SCI pain, is complex and has both emotional and physiological components, treatment should be multidisciplinary in nature and ideally tailored specifically to the patient.

Music Therapy for Anxiety and Pain After Spinal Cord Injury: A Pilot Study

Background

Music therapy (MT) programs have been used in various health care settings to reduce patients’ pain, anxiety, and stress. However, few studies have investigated its effects on patients with spinal cord injury (SCI), a frequently serious event requiring extensive rehabilitation.

Objective

This pilot study evaluated the feasibility of offering music-assisted relaxation (MAR) during rehabilitation for patients with SCI. We also measured the effect of MAR on the patients’ pain, anxiety, and stress levels.

Methods

Patients were hospitalized at Mayo Clinic (Rochester, Minnesota) from September 2015 through September 2017 for rehabilitation of an SCI. Eligible patients received 2, 20-minute, personalized MAR sessions. Interventions were facilitated by a board-certified music therapist (MT-BC) and included diaphragmatic breathing, guided imagery, and passive muscle relaxation with live guitar accompaniment and spoken, improvised, or singing voice. Two surveys (Generalized Anxiety Disorder [GAD-7] and Perceived Stress Scale [PSS-10]) were used at the time of study consent and again upon hospital dismissal. Pain, anxiety, and relaxation were assessed before and after both MT sessions with visual analog scales (VASs), scored from 0 to 10. Participants completed a 7-question satisfaction survey after the second MAR session.

Results

Twenty patients were enrolled (12 men, 8 women); 13 (65%) completed the MAR interventions. The mean (SD) age was 53.7 (17.7) years. VAS scores for pain significantly improved after both sessions (P ≤ .02). VAS scores for anxiety also significantly improved after both sessions (P ≤ .02), as did VAS scores for relaxation (P ≤ .02 for both). The satisfaction survey indicated that patients generally believed that they benefited from MT. Rehabilitation staff indicated that MT did not interfere with routine clinical care.

Conclusion

MT with live MAR is a feasible treatment for patients with SCI and may be effective for reducing their pain and anxiety.

Pregabalin and Gabapentin in Patients with Spinal Cord Injury-Related Neuropathic Pain: A Network Meta-Analysis

INTRODUCTION

This study was performed to explore the efficacy and safety of pregabalin and gabapentin in patients with spinal cord injury (SCI)-induced neuropathic pain to determine which treatment is most suitable for such patients.

METHODS

We searched the PubMed, MEDLINE, Embase, and Cochrane Library databases from database inception to August 31, 2020. The quality of the included studies was assessed. We selected the average pain intensity after treatment and the proportion of patients who discontinued treatment because of adverse effects as the outcome indicators for efficacy and safety, respectively. Statistical analyses were performed using Stata, v16.0, and RevMan, v5.3, software.

RESULTS

We included eight randomized controlled trials that examined four interventions (pregabalin, gabapentin, carbamazepine, and amitriptyline). Based on the average pain intensity after treatment, the efficacy order from highest to lowest was pregabalin, gabapentin, amitriptyline, carbamazepine, and placebo. Based on the proportion of patients who discontinued treatment because of adverse effects, the order from highest to lowest was pregabalin, amitriptyline, carbamazepine, gabapentin, and placebo. In addition, five studies reported the overall incidence of treatment-related adverse effects for two interventions (pregabalin and gabapentin). According to the pooled analysis of these studies, the order for the overall incidence of treatment-related adverse effects from highest to lowest was pregabalin, gabapentin, and placebo.

CONCLUSIONS

This study revealed that for patients with SCI-related neuropathic pain, pregabalin was the most effective for relieving pain, whereas gabapentin performed better in aspects associated with drug therapy-related safety.

Mediating Effects of Pain Interference on the Relationships Between Pain Intensity and Probable Major Depression Among Participants With Spinal Cord Injury

OBJECTIVE

To evaluate whether pain interference mediates the relationship between pain intensity and probable major depression (PMD) among persons with spinal cord injury (SCI), accounting for differences in the frequency of prescription medication use and resilience.

DESIGN

Cross-sectional analysis using self-report assessment.

SETTING

Medical university in the Southeastern United States.

PARTICIPANTS

There were a total of 4670 participants (N=4670), all of whom had traumatic SCI of at least 1-year duration, identified from the Southeastern Regional SCI Model System and 2 state-based surveillance systems.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9 was used to define PMD. Covariates included demographic and injury characteristics, pain severity, pain interference, and resilience. Separate sets of multistage logistic regression analyses were conducted for 3 levels of prescription pain medication use (daily, occasional/weekly, none).

RESULTS

Pain intensity was related to a greater risk of PMD (odds ratio [OR]_{daily pain medication user}, 1.28; 95% confidence interval [CI], 1.21-1.35; OR_{occasional/weekly pain medication user}, 1.26; 95% CI, 1.16-1.36; OR_{nonpain medication user}, 1.44; 95% CI, 1.33-1.56), but this relationship disappeared after consideration of pain interference (OR_{daily pain medication user}, 0.97; 95% CI, 0.90-1.04; OR_{occasional/weekly pain medication user}, 0.94; 95% CI, 0.84-1.05; OR_{nonpain medication user}, 1.07; 95% CI, 0.95-1.20), which indicates pain interference was a mediator between pain intensity and PMD and there was no direct relationship between pain intensity and PMD. Resilience was protective of PMD in each model but was not a mediator.

CONCLUSIONS

Although pain intensity was associated with PMD, the relationship was mediated by pain interference. Resilience was an important protective factor. Therefore, clinicians should assess pain interference when screening for PMD and direct treatment at reducing pain interference. Building resilience may further reduce the risk of PMD.

On the therapeutic targets and pharmacological treatments for pain relief following spinal cord injury: A mechanistic review

Spinal cord injury (SCI) is globally considered as one of the most debilitating disorders, which interferes with daily activities and life of the affected patients. Despite many developments in related recognizing and treating procedures, post-SCI neuropathic pain (NP) is still a clinical challenge for clinicians with no distinct treatments. Accordingly, a comprehensive search was conducted in PubMed, Medline, Scopus, Web of Science, and national database (SID and Irandoc). The relevant articles regarding signaling pathways, therapeutic targets and pharmacotherapy of post-SCI pain were also reviewed. Data were collected with no time limitation until November 2020. The present study provides the findings on molecular mechanisms and therapeutic targets, as well as developing the critical signaling pathways to introduce novel neuroprotective treatments of post-SCI pain. From the pathophysiological mechanistic point of view, post-SCI inflammation activates the innate immune system, in which the immune cells elicit secondary injuries. So, targeting the critical signaling pathways for pain management in the SCI population has significant importance in providing new treatments. Indeed, several receptors, ion channels, excitatory neurotransmitters, enzymes, and key signaling pathways could be used as therapeutic targets, with a pivotal role of n-methyl-D-aspartate, gamma-aminobutyric acid, and inflammatory mediators. The current review focuses on conventional therapies, as well as crucial signaling pathways and promising therapeutic targets for post-SCI pain to provide new insights into the clinical treatment of post-SCI pain. The need to develop innovative delivery systems to treat SCI is also considered.

Methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a systematic review

ABSTRACT

Mechanism-based classification of pain has been advocated widely to aid tailoring of interventions for individuals experiencing persistent musculoskeletal pain. Three pain mechanism categories (PMCs) are defined by the International Association for the Study of Pain: nociceptive, neuropathic, and nociplastic pain. Discrimination between them remains challenging. This study aimed to build on a framework developed to converge the diverse literature of PMCs to systematically review methods purported to discriminate between them; synthesise and thematically analyse these methods to identify the convergence and divergence of opinion; and report validation, psychometric properties, and strengths/weaknesses of these methods. The search strategy identified articles discussing methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system. Studies that assessed the validity of methods to discriminate between categories were assessed for quality. Extraction and thematic analysis were undertaken on 184 articles. Data synthesis identified 200 methods in 5 themes: clinical examination, quantitative sensory testing, imaging, diagnostic and laboratory testing, and pain-type questionnaires. Few methods have been validated for discrimination between PMCs. There was general convergence but some disagreement regarding findings that discriminate between PMCs. A combination of features and methods, rather than a single method, was generally recommended to discriminate between PMCs. Two major limitations were identified: an overlap of findings of methods between categories due to mixed presentations and many methods considered discrimination between 2 PMCs but not others. The results of this review provide a foundation to refine methods to differentiate mechanisms for musculoskeletal pain.

Pain and its impact on functioning and disability in manual wheelchair users with spinal cord injury: a protocol for a mixed-methods study

INTRODUCTION

Approximately 80% of people with spinal cord injury experience clinically significant chronic pain. Pain (whether musculoskeletal or neuropathic) is consistently rated as one of the most difficult problems to manage and negatively affects the individual's physical, psychological and social functioning and increases the risk of pain medication misuse and poor mental health. The aim of this study is to therefore determine the presence of pain and its impact on functioning and disability as well as to develop a framework for self-management of pain for South African manual wheelchair users with spinal cord injury.

METHODS AND ANALYSIS

Community-dwelling participants with spinal cord injury will be invited to participate in this three-phase study. Phase 1 will use a quantitative, correlational design to determine factors related to pain such as pectoralis minor length, scapular dyskinesis, wheelchair functioning, physical quality of life, community reintegration and pain medication misuse. Demographic determinants of pain such as age, gender, type of occupation, completeness of injury and neurological level of injury will also be investigated. Participants with pain identified in phase 1 will be invited to partake in a qualitative descriptive and contextually designed phase 2 to explore their lived experience of pain through in-depth interviews. The results of phases 1 and 2 will then be used with the assistance from experts to develop a framework for self-management of pain using a modified Delphi study. Data analysis will include descriptive and inferential statistics (quantitative data) and thematic content analysis (qualitative data).

ETHICS AND DISSEMINATION

Approval for this study is granted by the Faculty of Health Sciences Research Ethics Committee of the University of the Pretoria (approval number 125/2018). This study is registered with the South African National Health Research Database (reference GP201806005). This study's findings will be shared in academic conferences and published in scientific peer-reviewed journals.

Central pain syndromes

The management of pain in persons with neurological injuries is challenging and complex. A holistic view and clinical approach are necessary when addressing pain in patients with neurological impairment because interpreting signs and symptoms and deciphering sources of pain is never a straightforward process. This problem is further magnified with the management of central pain syndromes. The best approach is to have a good understanding of the clinical characteristics commonly found in this patient population, in particular for patients with stroke, multiple sclerosis (MS), or spinal cord injury (SCI), as central pain manifests differently between these groups. This paper will focus on the history, clinical presentation, pathophysiology, assessment, and treatment of central pain in patients with these types of neurological conditions. In addition to being at risk for a decline in quality of life, patients with pain syndromes are also prone to adverse responses to treatments (e.g., opioid addiction). It is therefore important to methodically analyze the similarities and differences between patients with different pain syndromes.

Associations between health behaviour, secondary health conditions and quality of life in people with spinal cord injury

Background

The development of secondary health conditions (SHCs) after spinal cord injury (SCI) is common and can affect an individual’s emotional well-being, and his or her health-related quality of life (QOL). Little is known about relationships between performing health-benefiting behaviours and the presence (or absence) of SHCs and QOL, particularly in South Africa.

Objectives

This research study was conducted in order to determine the associations between health behaviour, SHCs and QOL in people with SCI (PWSCI).

Method

This cross-sectional study included 36 PWSCI discharged from a private rehabilitation facility in Pretoria, South Africa. The PWSCI completed questionnaires pertaining to lifestyle, independence, presence of SHCs, social support and QOL. Data were analysed using descriptive and inferential statistics such as correlation tests and chi-square test of independence (x²) using the SPSS v25. Moderate, moderately high and high correlations are reported (Pearson r ≥ 0.4). Results were significant if p < 0.05.

Results

Participation in health-benefiting behaviour was associated with increased QOL (r = 0.457, p < 0.01) and increased social support from family and friends (r = 0.425, p < 0.01), which was associated with increased QOL (r = 0.671, p < 0.001). Not participating in specific neuromusculoskeletal health behaviours was found to be associated with the overall presence of SHCs (r = -0.426, p < 0.01).

Conclusions

Participating in health-benefiting behaviour can reduce the development of SHCs and subsequently increase QOL in PWSCI. Health professionals must focus on minimising the development of SHCs by providing specific education on good health-benefiting behaviour.

Spinal Cord Stimulation for Pain Treatment After Spinal Cord Injury

In addition to restoration of bladder, bowel, and motor functions, alleviating the accompanying debilitating pain is equally important for improving the quality of life of patients with spinal cord injury (SCI). Currently, however, the treatment of chronic pain after SCI remains a largely unmet need. Electrical spinal cord stimulation (SCS) has been used to manage a variety of chronic pain conditions that are refractory to pharmacotherapy. Yet, its efficacy, benefit profiles, and mechanisms of action in SCI pain remain elusive, due to limited research, methodological weaknesses in previous clinical studies, and a lack of mechanistic exploration of SCS for SCI pain control. We aim to review recent studies and outline the therapeutic potential of different SCS paradigms for traumatic SCI pain. We begin with an overview of its manifestations, classification, potential underlying etiology, and current challenges for its treatment. The clinical evidence for using SCS in SCI pain is then reviewed. Finally, future perspectives of pre-clinical research and clinical study of SCS for SCI pain treatment are discussed.

Spinal Cord Injury: How Could Acupuncture Help?

Spinal cord injury (SCI) is one of the most common causes of death and disability worldwide, and it can result in both permanent disability and serial complications in patients. Research shows that patients with SCI complications are often interested in acupuncture for symptomatic relief. Therefore, the issue of physicians advising their patients regarding the use of acupuncture to alleviate SCI complications becomes pertinent. We review and summarize two types of relevant publications: (1) literature concerning acupuncture for SCI and its complications and (2) underlying mechanisms of acupuncture therapy for SCI. Clinical trials and reviews have suggested that acupuncture effectively manages a range of post-SCI complications, including motor and sensory dysfunction, pain, neurogenic bowel and bladder, pressure ulcers, spasticity, and osteoporosis. The effect of acupuncture on post-SCI orthostatic hypotension and sexual dysfunction remains unclear. Decreased oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, and increased regenerative stem cell production are the possible mechanisms of acupuncture therapy for SCI. Although many limitations have been reported in previous studies, given the evidence for the efficacy of acupuncture, we recommend that physicians should support the use of acupuncture therapy for SCI complications.

Mental practice for chronic pain in people with spinal cord injury: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The primary objective of this systematic review is to identify the effects of mental practice (MP) interventions on chronic neuropathic and nociceptive pain and motor function recovery in individuals after spinal cord injury (SCI). Where possible, this review will also describe the optimal type and dosage (i.e. frequency, intensity and duration) of MP interventions for patients with SCI.

Patients receiving chiropractic care in a neurorehabilitation hospital: a descriptive study

Objectives

Individuals rehabilitating from complex neurological injury require a multidisciplinary approach, which typically does not include chiropractic care. This study describes inpatients receiving multidisciplinary rehabilitation including chiropractic care for brain injury, spinal cord injury (SCI), stroke, and other complex neurological conditions.

Design

Chiropractic services were integrated into Crotched Mountain Specialty Hospital (CMSH) through this project. Patient characteristics and chiropractic care data were collected to describe those receiving care and the interventions during the first 15 months when chiropractic services were available.

Setting

CMSH, a 62-bed subacute multidisciplinary rehabilitation, skilled nursing facility located in Greenfield, New Hampshire, USA.

Results

Patient mean (SD) age (n=27) was 42.8 (13) years, ranging from 20 to 64 years. Males (n=18, 67%) and those of white race/ethnicity (n=23, 85%) comprised the majority. Brain injury (n=20) was the most common admitting condition caused by trauma (n=9), hemorrhage (n=7), infarction (n=2), and general anoxia (n=2). Three patients were admitted for cervical SCI, 1 for ankylosing spondylitis, 1 for traumatic polyarthropathy, and 2 for respiratory failure with encephalopathy. Other common comorbid diagnoses potentially complicating the treatment and recovery process included myospasm (n=13), depression (n=11), anxiety (n=10), dysphagia (n=8), substance abuse (n=8), and candidiasis (n=7). Chiropractic procedures employed, by visit (n=641), included manual myofascial therapies (93%), mechanical percussion (83%), manual muscle stretching (75%), and thrust manipulation (65%) to address patients with spinal-related pain (n=15, 54%), joint or regional stiffness (n= 14, 50%), and extremity pain (n=13, 46%). Care often required adapting to participant limitations or conditions. Such adaptations not commonly encountered in outpatient settings where chiropractic care is usually delivered included the need for lift assistance, wheelchair dependence, contractures, impaired speech, quadriplegia/paraplegia, and the presence of feeding tubes and urinary catheters.

Conclusion

Patients suffered significant functional limitations and comorbidity resulting in modifications to the typical delivery of chiropractic care. Chiropractic services focused on relieving musculoskeletal pain and stiffness.

Chronic pain experience and pain management in persons with spinal cord injury in Nepal

BACKGROUND AND AIMS

Chronic pain is the frequent and significantly challenging complications in persons with spinal cord injury (SCI). Socio-cultural background may lead people perceive and manage pain differently. The study aims to describe the chronic pain experience and pain management of SCI persons in Nepal.

METHODS

A descriptive cross sectional study was conducted among purposively selected sample of 120 SCI persons with chronic pain living in the eight districts of Bagmati Zone of Nepal. The data were collected using the International Spinal Cord Injury Pain Basic Data Set Version 2 (ISCIPBDS-2) and Open-ended Pain Management Questionnaire. The data were analyzed using descriptive statistics and content analysis method.

RESULTS

The back (n=84), lower legs/feet (n=63) and buttocks/hips (n=51) was found as the common pain locations. In common, the onset of pain was found within the first 6 month of the injury. Overall pain intensity and pain interference were found to be at the moderate level. The SCI persons used pain medications and non-pharmacological pain management. Ibuprofen was the commonly used pain medication and commonly used non-pharmacological pain management methods included physical support (e.g. massage, exercise), relaxation (e.g. distraction, substance abuse), coping (e.g. acceptance, praying), and traditional herbs.

CONCLUSIONS

SCI persons had chronic pain experience which interfered with their daily living. They used pain medications and non-pharmacological pain management methods based on their beliefs, knowledge, and community resources in Nepal.

IMPLICATIONS

This study provides some evidence to help the team of rehabilitation professional to plan and help SCI persons with chronic pain. Based on these findings, chronic pain management intervention for SCI persons should be developed and supported continuously from hospital to home based community context of Nepal.

'Recover quicker, train harder, and increase flexibility': massage therapy for elite paracyclists, a mixed-methods study

Objectives

Massage therapy (MT) enhances recovery by reducing pain and fatigue in able-bodied endurance athletes. In athletes with disabilities, no studies have examined similar MT outcomes, yet participation in sport has increased by >1000 athletes from 1996 to 2016 Olympic games. We examined the effect of MT on pain, sleep, stress, function and performance goals on the bike, as well as quality of life off the bike, in elite paracycling athletes.

Methods

This is a quasi-experimental, convergent, parallel, mixed-methods design study of one team, with nine paracycling participants, in years 2015 and 2016. One-hour MT sessions were scheduled one time per week for 4 weeks, and then every other week for the duration of the time the athlete was on the team and/or in the study. Closed and open-ended survey questions investigating athlete goals, stress, sleep, pain and muscle tightness were gathered pre and post each MT session, and every 6 months for health-related quality of life. Quantitative analysis timepoints include baseline, 4-6 months of intervention and final visit. Additional qualitative data were derived from therapists' treatment notes, exit surveys, and follow-up emails from the athletes and therapists.

Results

Significant improvement was found for sleep and muscle tightness; quantitative results were reinforced by athlete comments indicating MT assisted in their recovery while in training. There were no improvements in dimensions measuring quality of life; qualitative comments from athletes suggest reasons for lack of improvement.

Conclusion

This real-world study provides new information to support MT for recovery in elite paracyclists.

Increased psychological distress among individuals with spinal cord injury is associated with central neuropathic pain rather than the injury characteristics

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Central neuropathic pain (CNP) is common after spinal cord injury (SCI). The psychological impact of CNP is not clear. Previous studies reported depression and pain catastrophizing among patients with SCI and CNP; however, the lack of control groups prevented discerning whether these were attributed to CNP or to the SCI itself. The aim was to examine the psychological distress among individuals with SCI with and without CNP and controls to evaluate its impact and possible source.

SETTING

Outpatient clinic of a large rehabilitation center.

METHODS

Individuals with SCI and CNP (n = 27) and without CNP (n = 23), and able-bodied controls (n = 20) participated. Data collection included sociodemographics, SCI characteristics, and level of post-traumatic stress disorder (PTSD), anxiety, stress, depression, and pain catastrophizing. The sensory, affective, and cognitive dimensions of CNP were analyzed.

RESULTS

Individuals with SCI and CNP exhibited elevated levels of PTSD, anxiety, stress, depression, and pain catastrophizing compared to the two control groups, which presented similar levels. The psychological variables among the CNP group correlated positively only with the affective dimension of CNP. Neither CNP nor the psychological variables correlated with SCI characteristics.

CONCLUSIONS

Irrespective of CNP intensity, the affective dimension (suffering) is associated with increased psychological distress. Perhaps individual differences in the response to SCI and/or individual traits rather than the mere exposure to SCI may have a role in the emergence of CNP and psychological distress/mood dysfunction. Rehabilitation programs should prioritize stress management and prevention among individuals with SCI and CNP.

Interdisciplinary rehabilitation for a patient with incomplete cervical spinal cord injury and multimorbidity: A case report

RATIONALE

This report describes interdisciplinary rehabilitation for a 51-year-old male recovering from incomplete cervical spinal cord injury (SCI) and multiple comorbidities following an automobile accident.

PATIENT CONCERNS

The patient was admitted to a rehabilitation specialty hospital approximately 2 months post SCI and 2 separate surgical fusion procedures (C3-C6).

DIAGNOSES

Clinical presentation at the rehabilitation hospital included moderate to severe motor strength loss in both upper and lower extremities, a percutaneous endoscopic gastronomy tube (PEG), dysphagia, bowel/bladder incontinence, dependence on a mechanical lift and tilting wheelchair due to severe orthostatic hypotension, and pre-existing shoulder pain from bilateral joint degeneration.

INTERVENTIONS

The interdisciplinary team formally coordinated rehabilitative care from multiple disciplines. Internal medicine managed medications, determined PEG removal, monitored co-morbid conditions, and overall progress. Chiropractic care focused on alleviating shoulder and thoracic pain and improving spinal and extremity mobility. Physical therapy addressed upright tolerance, transfer, gait, and strength training. Occupational therapy focused on hand coordination and feeding/dressing activities. Psychology assisted with coping strategies. Nursing ensured medication adherence, nutrient intake, wound prevention, and incontinence management, whereas physiatry addressed abnormal muscle tone.

OUTCOMES

Eleven months post-admission the patient's progress allowed discharge to a long-term care facility. At this time he was without dysphagia or need for a PEG. Orthostatic hypotension and bilateral shoulder pain symptoms were also resolved while bowel/bladder incontinence and upper and lower extremity motor strength loss remained. He was largely independent in transferring from bed to wheelchair and in upper body dressing. Lower body dressing/bathing required maximal assistance. Gait with a 2-wheeled walker was possible up to 150 feet with verbal cues and occasional stabilizing assistance.

LESSONS

Several specialties functioning within an interdisciplinary team fulfilled complementary roles to support rehabilitation for a patient with SCI.

Auricular acupuncture for spinal cord injury related neuropathic pain: a pilot controlled clinical trial

OBJECTIVE

To obtain preliminary data on the effects of an auricular acupuncture protocol, Battlefield Acupuncture (BFA), on self-reported pain intensity in persons with chronic Spinal Cord Injury (SCI) and neuropathic pain.

DESIGN

Pilot randomized delayed entry single center crossover clinical trial at an outpatient rehabilitation and integrative medicine hospital center.

METHODS

Chronic (> one year post injury) ASIA impairment scale A through D individuals with SCI with injury level from C3 through T12 and below level neuropathic pain with at least five on the Numeric Rating Scale (NRS) were recruited. Twenty-four subjects were randomized to either an eight-week once weekly ten-needle BFA protocol (n = 13) or to a waiting list followed by the BFA protocol (n = 11).

OUTCOME MEASURES

The primary outcome measure was change in the pain severity NRS. Secondary outcome was the Global Impression of Change.

RESULTS

Demographically there were no significant differences between groups. Mean pain scores at baseline were higher in acupuncture than control subjects (7.75 ± 1.54 vs. 6.25 ± 1.04, P = 0.027). Although both groups reported significant reduction in pain during the trial period, the BFA group reported more pain reduction than the delayed entry group (average change in NRS at eight weeks -2.92 ± 2.11 vs. -1.13 ± 2.14, P = 0.065). There was a significant difference in groups when a group-by-time interaction in a mixed-effect repeated measures model (P = 0.014).

CONCLUSION

This pilot study has provided proof of concept that BFA has clinically meaningful effect on the modulation of SCI neuropathic pain.

Outcomes and reflections on a consensus-building workshop for developing a spinal cord injury-related chronic pain research agenda

Context/ Objective: Chronic pain following spinal cord injury (SCI) is a prevalent secondary health condition that significantly impacts quality of life (QoL). Although growing, the number of available effective pain management approaches for SCI is limited. Recognizing the need to "kick-start" activity on this topic, a consensus-building workshop on developing a research agenda for SCI-related chronic pain was held in 2006 with an expert panel. The present paper describes the processes of the consensus-workshop and its associated outcomes towards advancing the research agenda for SCI-related pain in Canada. A commentary on the current state of knowledge regarding SCI-related pain is also provided.

METHODS

Thirty-nine stakeholders (researchers, clinicians, policy-makers, SCI advocates, and people with SCI) attended the consensus-workshop. A modified Delphi approach was employed to gain consensus on identifying the top five SCI pain research priorities for improving QoL post-SCI. As well, project planning along with infrastructure support opportunities were discussed.

RESULTS

The top five pain research priorities were: 1) pain management and treatment; 2) measurement tools; 3) health services policy and advocacy; 4) knowledge transfer; and 5) mechanisms of pain. Recommendations related to the priorities and related resources were generated, and pilot work was initiated.

CONCLUSIONS

The consensus workshop provided an initial roadmap for research on SCI-related chronic pain, and supported five pilot projects on the identified priorities. Reflections on the current research landscape in Canada and abroad suggest increased activity towards addressing pain post-SCI but evidence-based approaches are still lacking.

Traumatic spinal cord injury

Traumatic spinal cord injury (SCI) has devastating consequences for the physical, social and vocational well-being of patients. The demographic of SCIs is shifting such that an increasing proportion of older individuals are being affected. Pathophysiologically, the initial mechanical trauma (the primary injury) permeabilizes neurons and glia and initiates a secondary injury cascade that leads to progressive cell death and spinal cord damage over the subsequent weeks. Over time, the lesion remodels and is composed of cystic cavitations and a glial scar, both of which potently inhibit regeneration. Several animal models and complementary behavioural tests of SCI have been developed to mimic this pathological process and form the basis for the development of preclinical and translational neuroprotective and neuroregenerative strategies. Diagnosis requires a thorough patient history, standardized neurological physical examination and radiographic imaging of the spinal cord. Following diagnosis, several interventions need to be rapidly applied, including haemodynamic monitoring in the intensive care unit, early surgical decompression, blood pressure augmentation and, potentially, the administration of methylprednisolone. Managing the complications of SCI, such as bowel and bladder dysfunction, the formation of pressure sores and infections, is key to address all facets of the patient's injury experience.

Symptom-Based Treatment of Neuropathic Pain in Spinal Cord-Injured Patients: A Randomized Crossover Clinical Trial

OBJECTIVE

The objective of this study was to identify the differences in medication effect according to pain characteristics in spinal cord-injured patients.

METHODS

This study is a prospective, randomized, crossover study. Fifty-five patients and 66 locations of neuropathic pain were included. Pain was classified into four spontaneous characteristics and three evoked pain characteristics. Oxcarbazepine (Na channel blocker) and pregabalin (calcium channel α2-δ ligand medication) were tried. Patients were divided into two groups: evoked pain present and evoked pain absent. Overall average visual analog scale was obtained.

RESULTS

Oxcarbazepine was significantly more effective for patients without evoked pain than in those with it for electrical, burning, and pricking pain. The effect of pregabalin was not different regarding the presence or absence of evoked pain for all pain categories, except burning pain. In patients with evoked pain, pregabalin was shown to be significantly more effective for electrical pain, allodynia, and heat hyperalgesia than oxcarbazepine. In the evoked pain absent group, oxcarbazepine showed greater improvement than pregabalin but was not significant.

CONCLUSIONS

In summary, the phenotype of neuropathic pain was associated with the efficacy of different pharmacologic treatments. Symptom-based treatment, therefore, can lead to more efficient analgesia.

Central Neuropathic Pain Syndromes

Chronic pain is common in patients with neurologic complications of a central nervous system insult such as stroke. The pain is most commonly musculoskeletal or related to obligatory overuse of neurologically unaffected limbs. However, neuropathic pain can result directly from the central nervous system injury. Impaired sensory discrimination can make it challenging to differentiate central neuropathic pain from other pain types or spasticity. Central neuropathic pain may also begin months to years after the injury, further obscuring recognition of its association with a past neurologic injury. This review focuses on unique clinical features that help distinguish central neuropathic pain. The most common clinical central pain syndromes-central poststroke pain, multiple sclerosis-related pain, and spinal cord injury-related pain-are reviewed in detail. Recent progress in understanding of the pathogenesis of central neuropathic pain is reviewed, and pharmacological, surgical, and neuromodulatory treatments of this notoriously difficult to treat pain syndrome are discussed.

Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury

RATIONALE

Optimal, early management following a spinal cord injury (SCI) can limit individuals' disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting.

OBJECTIVES

To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients.

METHODS

The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application.

RESULTS

Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures.

CONCLUSIONS

This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients.

Pain and spinal cord imaging measures in children with demyelinating disease

Pain is a significant problem in diseases affecting the spinal cord, including demyelinating disease. To date, studies have examined the reliability of clinical measures for assessing and classifying the severity of spinal cord injury (SCI) and also to evaluate SCI-related pain. Most of this research has focused on adult populations and patients with traumatic injuries. Little research exists regarding pediatric spinal cord demyelinating disease. One reason for this is the lack of reliable and useful approaches to measuring spinal cord changes since currently used diagnostic imaging has limited specificity for quantitative measures of demyelination. No single imaging technique demonstrates sufficiently high sensitivity or specificity to myelin, and strong correlation with clinical measures. However, recent advances in diffusion tensor imaging (DTI) and magnetization transfer imaging (MTI) measures are considered promising in providing increasingly useful and specific information on spinal cord damage. Findings from these quantitative imaging modalities correlate with the extent of demyelination and remyelination. These techniques may be of potential use for defining the evolution of the disease state, how it may affect specific spinal cord pathways, and contribute to the management of pediatric demyelination syndromes. Since pain is a major presenting symptom in patients with transverse myelitis, the disease is an ideal model to evaluate imaging methods to define these regional changes within the spinal cord. In this review we summarize (1) pediatric demyelinating conditions affecting the spinal cord; (2) their distinguishing features; and (3) current diagnostic and classification methods with particular focus on pain pathways. We also focus on concepts that are essential in developing strategies for the detection, monitoring, treatment and repair of pediatric myelitis.

•

Pain is a major presenting symptom in children with myelitis.

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Currently used imaging has limited sensitivity to myelin content.

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We provide a summary on pediatric demyelinating conditions.

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We review pain involvement and pathways affected by demyelination.

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We review imaging modalities for the diagnosis and monitoring of myelitis.

Management of Neuropathic Pain Associated with Spinal Cord Injury

Spinal cord injury (SCI) is an injury to the spinal cord that leads to varying degrees of motor and/or sensory deficits and paralysis. Chronic pain of both neuropathic and nociceptive type is common and contributes to reduced quality of life. The aim of the review is to provide current clinical understanding as well as discuss and evaluate efficacy of pharmacological interventions demonstrated in the clinical studies. The review was based on literature search in PubMed and Medline with words "neuropathic pain" and "spinal cord injury". The review included clinical studies and not experimental data nor case reports. A limited number of randomized and placebo-controlled studies concerning treatment options of neuropathic pain after SCI were identified. Amitriptyline, a tricyclic antidepressant and the antiepileptic drugs, gabapentin and pregabalin, are most studied with demonstrated efficacy, and considered to be the primary choice. Opioids have demonstrated conflicting results in the clinical studies. In addition, administration route used in the studies as well as reported side effects restrict everyday use of opioids as well as ketamine and lidocaine. Topical applications of capsaicin or lidocaine as well as intradermal injections of Botulinum toxin are new treatment modalities that are so far not studied on SCI population and need further studies. Non-pharmacological approaches may have additional effect on neuropathic pain. Management of pain should always be preceded by thorough clinical assessment of the type of pain. Patients need a follow-up to evaluate individual effect of applied measures. However, the applied management does not necessarily achieve satisfactory pain reduction. Further clinical studies are needed to evaluate the effect of both established and novel management options.

Antidepressants Are Effective in Decreasing Neuropathic Pain After SCI: A Meta-Analysis

OBJECTIVE

To systematically review and assess the effectiveness and safety of antidepressants for neuropathic pain among individuals with spinal cord injury (SCI).

METHODS

A systematic search was conducted using multiple databases for relevant articles published from 1980 to April 2014. Randomized controlled trials (RCTs) involving antidepressant treatment of neuropathic pain with ≥ 3 individuals and ≥ 50% of study population with SCI were included. Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference, standard error, and 95% confidence interval for primary (pain) and other secondary outcomes was conducted.

RESULTS

Four RCTs met inclusion criteria. Of these, 2 studies assessed amitriptyline, 1 trazadone, and 1 duloxetine among individuals with neuropathic SCI pain. A small effect was seen in the effectiveness of antidepressants in decreasing pain among individuals with SCI (standardized mean difference = 0.34 ± 0.15; 95% CI, 0.05-0.62; P = .02). A number needed to treat of 3.4 for 30% or more pain relief was found by pooling 2 studies. Of these, significantly higher risk of experiencing constipation (risk ratio [RR] = 1.74; 95% CI, 1.09-2.78; P = .02) and dry mouth (RR = 1.39; 95% CI, 1.04-1.85; P = .02) was found amongst individuals receiving antidepressant treatment compared to those in the control group.

CONCLUSIONS

The current meta-analysis demonstrates that antidepressants are effective in reducing neuropathic SCI pain. However, this should be interpreted with caution due to the limited number of studies. Further evaluation of long-term therapeutic options may be required.

Viral vectors encoding endomorphins and serine histogranin attenuate neuropathic pain symptoms after spinal cord injury in rats

Background

The treatment of spinal cord injury (SCI)-induced neuropathic pain presents a challenging healthcare problem. The lack of available robust pharmacological treatments underscores the need for novel therapeutic methods and approaches. Due to the complex character of neuropathic pain following SCI, therapies targeting multiple mechanisms may be a better choice for obtaining sufficient long-term pain relief. Previous studies in our lab showed analgesic effects using combinations of an NMDA antagonist peptide [Ser¹]histogranin (SHG), and the mu-opioid peptides endomorphins (EMs), in several pain models. As an alternative to drug therapy, this study evaluated the analgesic potential of these peptides when delivered via gene therapy.

Results

Lentiviruses encoding SHG and EM-1 and EM-2 were intraspinally injected, either singly or in combination, into rats with clip compression SCI 2 weeks following injury. Treated animals showed significant reduction in mechanical and thermal hypersensitivity, compared to control groups injected with GFP vector only. The antinociceptive effects of individually injected components were modest, but the combination of EMs and SHG produced robust and sustained antinociception. The onset of the analgesic effects was observed between 1–5 weeks post-injection and sustained without decrement for at least 7 weeks. No adverse effects on locomotor function were observed. The involvement of SHG and EMs in the observed antinociception was confirmed by pharmacologic inhibition using intrathecal injection of either the opioid antagonist naloxone or an anti-SHG antibody. Immunohistochemical analysis showed the presence of SHG and EMs in the spinal cord of treated animals, and immunodot-blot analysis of CSF confirmed the presence of these peptides in injected animals. In a separate group of rats, delayed injection of viral vectors was performed in order to mimic a more likely clinical scenario. Comparable and sustained antinociceptive effects were observed in these animals using the SHG-EMs combination vectors compared to the group with early intervention.

Conclusions

Findings from this study support the potential for direct gene therapy to provide a robust and sustained alleviation of chronic neuropathic pain following SCI. The combination strategy utilizing potent mu-opioid peptides with a naturally-derived NMDA antagonist may produce additive or synergistic analgesic effects without the tolerance development for long-term management of persistent pain.

The effect of repetitive transcranial magnetic stimulation on refractory neuropathic pain in spinal cord injury

OBJECTIVE

To investigate the analgesic effect of repetitive transcranial magnetic stimulation (rTMS) on intractable neuropathic pain in patients with spinal cord injury (SCI).

DESIGN

A single center, prospective, randomized, double-blinded, controlled study.

SETTING

SCI rehabilitation unit of university rehabilitation center.

PARTICIPANTS

Seventeen patients with SCI and chronic neuropathic pain who met the inclusion criteria recruited between April 2010 and January 2012.

INTERVENTIONS

Ten daily treatment sessions of real or sham rTMS (30 trains of 10-Hz stimuli for a duration of 5 seconds; a total of 1500 pulses at intensity equal to 110% of the resting motor threshold) was applied over vertex using a figure-of-8-shaped coil.

OUTCOME MEASURES

Pain was assessed with visual analog scale (VAS) at baseline and 10 days, 6 weeks and 6 months after the treatment. Patients' satisfactions obtained using a 5-point Likert scale at 6 months.

RESULTS

Both real and sham rTMS provided a significant reduction in the VAS scores (real rTMS group, P = 0.004; sham rTMS group, P = 0.020). Post hoc analysis revealed the significant difference was at 10 days and 6 weeks compared to baseline in the real rTMS group and only at 10 days compared to baseline in the sham rTMS group. Comparison of VAS scores and patient satisfaction did not show any significant difference at each assessment point (P > 0.05).

CONCLUSION

Our results demonstrated analgesic effect of rTMS on intractable neuropathic pain in SCI was not superior to placebo. However, middle-term (over 6 weeks) pain relief by rTMS is encouraging and suggests the need for future studies with a larger sample size.

Multidimensional clinical pain phenotypes after spinal cord injury

SUMMARY Persistent neuropathic pain after spinal cord injury (SCI) is a serious problem that significantly affects general health and wellbeing over and above what is caused by other medical consequences after SCI. The ideal approach to the management of the neuropathic pain conditions after SCI would be to identify the primary contributing mechanisms of pain in each person and tailor the treatment to these. However, despite significant basic and clinical research progress, this approach remains elusive. One strategy to further this effort is to define neuropathic pain phenotypes based on pain symptoms, sensory function/dysfunction and psychosocial factors, and determine the relationship between these and treatment outcomes and biomarkers including brain imaging. This approach will facilitate the interaction between basic and clinical science and translational research, further the understanding of the mechanisms that contribute to the development and maintenance of neuropathic pain after SCI, and thus the development of effective mechanisms-based pain treatment strategies.

Patients' perspectives on pain

Nociceptive and neuropathic pain (NP) are common consequences following spinal cord injury (SCI), with large impact on sleep, mood, work, and quality of life. NP affects 40% to 50% of individuals with SCI and is sometimes considered the major problem following SCI. Current treatment recommendations for SCI-NP primarily focus on pharmacological strategies suggesting the use of anticonvulsant and antidepressant drugs, followed by tramadol and opioid medications. Unfortunately, these are only partly successful in relieving pain. Qualitative studies report that individuals with SCI-related long-lasting pain seek alternatives to medication due to the limited efficacy, unwanted side effects, and perceived risk of dependency. They spend time and money searching for additional treatments. Many have learned coping strategies on their own, including various forms of warmth, relaxation, massage, stretching, distraction, and physical activity. Studies indicate that many individuals with SCI are dissatisfied with their pain management and with the information given to them about their pain, and they want to know more about causes and strategies to manage pain. They express a desire to improve communication with their physicians and learn about reliable alternative sources for obtaining information about their pain and pain management. The discrepancy between treatment algorithms and patient expectations is significant. Clinicians will benefit from hearing the patient´s voice.

Holistic Health and People With Spinal Cord Injuries

We examined the perspectives of rehabilitation professionals in British Columbia on the use of holistic practices (HP) by their clients with spinal cord injury (SCI). This was a qualitative descriptive study with 13 rehabilitation professionals.Results show that health care practitioners serving those with SCI noted interest in and use of HP between 75% and 90% among their client groups. Most rehabilitation professionals already work in an interdisciplinary fashion with HP practitioners. Some were skeptical about HP, others saw a great benefit to their clients and others still only pursued HP when asked about it by their clients. Conclusions are that health care professionals are willing to acquire more knowledge about HP to provide the best available care. Participants showed interest in incorporating other aspects of health care to aid rehabilitation.

Acupuncture for spinal cord injury and its complications: a systematic review and meta-analysis of randomized controlled trials

To evaluate the evidence supporting the effectiveness of acupuncture treatment for SCI and its complications, we conducted search across 19 electronic databases to find all of the randomized controlled trials (RCTs) that used acupuncture as a treatment for SCI and its complications. The methodological quality of each RCT was assessed using the Cochrane risk of bias tool and the PEDro scale. Sixteen RCTs, including 2 high-quality RCTs, met our inclusion criteria (8 for functional recovery from SCI, 6 for bladder dysfunction, and 2 for pain control). The meta-analysis showed positive results for the use of acupuncture combined with conventional treatments for the functional recovery in terms of motor ASIA scores and total FIM scores when compared to conventional treatments alone. Positive results were also obtained for the treatment of bladder dysfunction, in terms of the total efficacy rate, when comparing acupuncture to conventional treatments. However, 2 RCTs for pain control reported conflicting results. Our systematic review found encouraging albeit limited evidence for functional recovery, bladder dysfunction, and pain in SCI. However, to obtain stronger evidence without the drawbacks of trial design and the quality of studies, we recommend sham-controlled RCTs or comparative effectiveness research for each condition to test the effectiveness of acupuncture.

Oxycodone improves pain control and quality of life in anticonvulsant-pretreated spinal cord-injured patients with neuropathic pain

STUDY DESIGN

A 3-month follow-up, observational, prospective, multicenter, study in traumatic spinal cord-injured (SCI) patients with neuropathic pain (NP).

OBJECTIVES

To assess the effectiveness and safety of oxycodone treatment in SCI patients with anticonvulsants-refractory NP.

SETTING

'Spinal injury follow-up units' throughout Spain.

METHODS

Data regarding NP characteristics were collated from male and female adults with traumatic SCI and difficult-to-control central NP of moderate-to-severe intensity (visual analog scale (VAS) ≥4) persisting ≥1 month, who had been para- or tetraplegic for ≥2 months, had been previously treated with anticonvulsants and were now treated with oxycodone.

RESULTS

In all, 54 out of the 57 patients recruited were assessable. A total of 81% were men and the mean age was 46.4. Patients were treated with oxycodone, 83% combined with anticonvulsant. Pain intensity (VAS: 7.1 ± 1.3-4.3 ± 1.7) and Lattinen total score (13.2 ± 3-7.7 ± 3.4) decreased significantly (P < 0.001) along the study. No patient got worse regarding pain impact on physical activity and on sleep (Lattinen scale). EQ-5D VAS showed a trend to increase (P = 0.061) and the index of preference values increased significantly from baseline to month 3 (0.26-0.62; P < 0.001). A total of 53.7% patients showed at least one treatment-related adverse event, with constipation being the most frequent one (33.3%).

CONCLUSION

Oxycodone treatment, mostly in combination with anticonvulsants, in SCI patients with NP decreases pain intensity, improves health-related quality of life and diminishes the impact of pain on physical activity and sleep.