The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: Recommendations for treatment

Chronic Use of Prescription Pain Medication and Outcomes in Patients With Burn Injury: A Burn Model System National Database Study

OBJECTIVE

This study attempts to examine long-term pain medication usage after burn injury and its association with functional and psychosocial outcomes.

DESIGN

This is a multicenter retrospective cohort study utilizing the Burn Model System National Longitudinal Database. Participants injured from 2015 to 2021 were divided into two groups, those taking and not taking prescription pain medication at 12 mos after injury. Regression analyses examined associations between pain medication use and outcomes at 12 mos, adjusting for demographics, burn size, length of hospital stay, and preinjury pain medication use and employment status. Outcomes included VR-12 Physical and Mental Component Summary scores Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores, Satisfaction with Life Scale, and employment status.

RESULTS

Of 358 participants analyzed, prescription pain medication use was associated with worse outcomes at 12 mos: Physical Component Summary (β = -7.11, P < 0.001), Mental Component Summary (β = -6.01, P < 0.001), and Patient-Reported Outcomes Measurement Information System Depression (β = 4.88, P < 0.001) and Anxiety (β = 6.16, P < 0.001). Satisfaction with Life Scale was not significantly associated with pain medication use ( P = 0.069) and those taking pain medication were 52% less likely to be employed at 12 mos ( P = 0.035).

CONCLUSIONS

There is a significant association between prescription pain medication use and worse physical, mental, and employment outcomes at 12 mos after burn injury.

Randomised, double-blind, placebo-controlled, parallel-group, multicentric, phase IIA clinical trial for evaluating the safety, tolerability, and therapeutic efficacy of daily oral administration of NFX88 to treat neuropathic pain in individuals with spinal cord injury

STUDY DESIGN

Double-blind, randomized, placebo-controlled, parallel-group multicentric phase IIA clinical trial.

OBJECTIVE

To assess the safety and tolerability of oral administration of NFX-88 in subjects with chronic spinal cord injury (SCI) and explore its efficacy in pain control.

SETTING

A total of 7 spinal cord injury rehabilitation units in Spain.

METHODS

A total of 61 adult with traumatic complete or incomplete spinal cord injury (C4-T12 level), were randomised 1:1:1:1 to a placebo, NFX88 1.05 g, 2.1 g, 4.2 g/day for up to 12 weeks. The placebo or NFX-88 was administered as add-on therapy to pre-existing pregabalin (150-300 mg per day). Safety and tolerability were evaluated, and the Visual Analogue Scale (VAS) was the primary measure to explore the efficacy of NFX-88 in pain control.

RESULTS

No severe treatment-related adverse effects were reported for any of the four study groups. 44 SCI individuals completed the study and were analysed. The data obtained from the VAS analysis and the PainDETECT Questionnaire (PD-Q) suggested that the combination of NFX88 with pregabalin is more effective than pregabalin with placebo at reducing neuropathic pain (NP) in individuals with SCI and that the dose 2.10 g/day causes the most dramatic pain relief.

CONCLUSIONS

NFX88 treatment was found to be highly safe and well tolerated, with the dose of 2.10 g/day being the most effective at causing pain relief. Thus, the promising efficacy of this first-in-class lipid mediator deserves further consideration in future clinical trials.

Choosing non-pharmacological treatments for neuropathic pain in spinal cord injury: a qualitative study

PURPOSE

The aims of this study were to explore (1) the considerations of people with spinal cord injury (SCI) in choosing to use non-pharmacological treatments (N-PTs) for neuropathic pain (NP), (2) which factors influence their decision and who is involved in this choice.

MATERIALS AND METHODS

Eleven individuals with SCI and NP were interviewed. Interviews were transcribed verbatim, transcripts were analysed through thematic coding, following an inductive content analysis approach.

RESULTS

A journey towards finding and choosing N-PTs emerged. Key phases in this journey were: motives, strategy and practical considerations. Pain and its impact on their life led participants to consider N-PTs. Motives were participants' negative attitudes towards regular medication, willingness to try everything and disappointment and frustration with the guidance from their health care provider (HCP). The search strategies often involved third parties and the internet. This led them to choose a specific N-PT. The journey was influenced by one's attitude, previous personal experience, experience of HCPs, financial considerations, availability and convenience of the treatment.

CONCLUSIONS

The journey individuals with SCI and NP go through to find N-PTs to manage pain is difficult and often lonely. Findings highlight the importance of HCPs accompanying people with SCI in finding N-PTs.

Treatments perceived to be helpful for neuropathic pain after traumatic spinal cord injury: A multicenter cross-sectional survey study

DESIGN

Cross-sectional survey.

OBJECTIVE

To evaluate the perceived helpfulness of pharmacological and non-pharmacological interventions and their combinations for neuropathic pain (NeuP) and subcategories of NeuP after spinal cord injury (SCI).

SETTING

Six Spinal Cord Injury Model System Centers.

METHODS

Three hundred ninety one individuals at least one year post traumatic SCI were enrolled. A telephone survey was conducted to determine the pharmacologic and non-pharmacologic treatments used in the last 12 months for each participant's three worst pains, whether these treatments were "helpful", and if currently used, each treatments' effectiveness.

RESULTS

Two hundred twenty participants (56%) reported 354 distinct NeuPs. Pharmacological treatments rated helpful for NeuP were non-tramadol opioids (opioids were helpful for 86% of opioid treated NeuPs), cannabinoids (83%), and anti-epileptics (79%). Non-pharmacological treatments rated helpful for NeuP were massage (76%), body position adjustment (74%), and relaxation therapy (70%). Those who used both opioids and exercise reported greater NeuP treatment helpfulness compared to participants using opioids without exercise (P = 0.03).

CONCLUSIONS

Opioids, cannabinoids, and massage were reported more commonly as helpful than treatments recommended as first-line therapies by current clinical practice guidelines (CPGs) for NeuP after SCI (antiepileptics and antidepressants). Individuals with SCI likely value the modulating effects of pharmacological and non-pharmacological treatments on the affective components of pain in addition to the sensory components of pain when appraising treatment helpfulness.

Quality appraisal of clinical practice guidelines addressing massage interventions using the AGREE II instrument

OBJECTIVE

The purpose of this study was to systematically evaluate the methodological quality of massage-related clinical practice guidelines (CPGs)/consensus on massage using the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument and to summarize the current status of recommendations in the CPGs.

METHODS

The Chinese National Knowledge Infrastructure (CNKI), WanFang Data, China Science and Technology Journal Database (VIP), China Biology Medicine disc (CBM), PubMed, Embase, and guideline websites (such as the Chinese Medical Ace Base, the China Association of Chinese Medicine, the World Health Organization, Guideline International Network, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network) were searched from inception to October 31, 2022. In addition, the reference lists of relevant studies were reviewed to identify domestic and overseas massage CPGs/consensus. The search terms adopted a combination of subject words and free words, mainly including traditional Chinese medicine, complementary therapies, Tuina, massage, manipulation, chiropractic/osteopathic, spinal, acupressure, guideline, and consensus. Two researchers independently completed the eligible records and extracted the data. Before the formal research, calibrations were performed twice on AGREE II, and all reviewers completed the pilot test three times until they understood and reached an agreement on the assessment items. Three researchers appraised the methodological quality of the included guidelines using the AGREE II instrument and calculated the overall intraclass correlation coefficient (ICC) of agreement.

RESULTS

The evaluation results showed that among the 49 eligible CPGs/consensus, 4 (8.2%) CPGs/consensus were considered "recommended", 15 (30.6%) CPGs/consensus were considered "recommended with modifications", and 30 (61.2%) CPGs/consensus were considered "not recommended", while the consensus was considered "not recommended". Generally, the scores in the six domains of the guidelines were all higher than the consensus. Evaluation results for the overall quality of 36 CPGs showed that 4 (11%) were "good quality", 15 (42%) were "sufficient quality" and 17 (47%) were "lower quality". The AGREE II quality scores of domains ranged from 0.30 to 0.75 ([ICC = 0.993, 95% CI (0.992, 0.995)]). The domain of scope and purpose (domain 1), with a median score of 0.75 (0.52~0.91), performed best in the guidelines with AGREE II, and stakeholder involvement (domain 2) [median 0.39 (0.31~0.56)] and application (domain 5) [median 0.30 (0.17~0.47] obtained lower scores. The consensus score of domain 1 was better at 26.0 (21.6~44.8), followed by rigor of development (domain 3) with a score of 18.0 (10.0~28.9). A total of 119 massage-related recommendations were extracted from 49 guidelines/consensuses, including "in favor" (102, 85.7%), "against" (9, 7.6%), and "did not make recommendations" (8, 6.7%).

CONCLUSION

The overall quality of the included guidelines was low, and most of the guidelines were not "recommended". In future guideline updates, the existing evidence should be used, the professional composition of members of the expert group should be enriched, and patients' values and preferences should be fully considered. It is necessary to clearly propose recognizable recommendations and strengthen the rigor and standardization of guideline formulation. Thus, clear standard guidelines can be formulated to better guide clinical practice.

Indicators of publicly funded prescription opioid use among persons with traumatic spinal cord injury in Ontario, Canada

OBJECTIVE

To describe the proportion and identify predictors of community-dwelling individuals with traumatic spinal cord injury (TSCI) who were dispensed ≥1 publicly funded opioid in the year after injury using a retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS, INTERVENTIONS, OUTCOME MEASURES

We used administrative data to identify predictors of receiving publicly funded prescription opioids during the year after injury for individuals who were injured between April 2004 and March 2015. Our outcome was modeled using robust Poisson multivariable regression and we reported adjusted relative risks (aRR) with 95% confidence intervals.

RESULTS

In our retrospective cohort of 934 individuals with TSCI who were eligible for the provincial drug program, 510 (55%) received ≥1 prescription opioid in the year after their injury. Most individuals were male (71%) and the median age was 63 years (interquartile range: 42-72). Being male (aRR 1.15, 95% confidence interval [CI] 1.01-1.31), having chronic obstructive pulmonary disease (aRR 1.25, 95% CI 1.05-1.50), and using prescription opioids before injury (aRR 1.46, 95% CI 1.29-1.66) were significantly associated with receiving opioids in the year after TSCI. Short durations of hospital stay after injury were also identified as being a significant risk factor of outpatient opioid use (aRR = 1.28, 95% CI = 1.08-1.51) when compared to longer hospital stays.

CONCLUSION

This study presented evidence showing that most individuals eligible for Ontario's public drug program who experienced a TSCI used opioids in the year following their injury. Due to the paucity of research on this population and their potential for elevated risks of adverse events, it is important for additional studies to be conducted on opioid use in this population to understand short-term and long-term risks and benefits.

Feasibility of using remotely delivered Spring Forest Qigong to reduce neuropathic pain in adults with spinal cord injury: a pilot study

Introduction: Approximately 69% of 299,000 Americans with spinal cord injury (SCI) suffer debilitating chronic neuropathic pain, which is intractable to treatment. The aim of this study is to determine feasibility, as the primary objective, and estimates of efficacy of a remotely delivered Qigong intervention in adults with SCI-related neuropathic pain, as the secondary objective. Methods: We recruited adults with SCI-related neuropathic pain, with SCI ≥3 months, with complete or incomplete SCI, and highest neuropathic pain level of >3 on the Numeric Pain Rating Scale (NPRS), using nationwide volunteer sampling. Using a non-randomized controlled trial design, participants practiced Spring Forest Qigong's "Five Element Qigong Healing Movements" (online video) by combining movement to the best of their ability with kinesthetic imagery, at least 3x/week for 12 weeks. Adherence was automatically tracked through the Spring Forest Qigong website. Outcomes of neuropathic pain intensity (NPRS) were assessed weekly, and SCI-related symptoms were assessed at baseline, 6, and 12 weeks of Qigong practice and at 6-week and 1-year follow-ups. Results: We recruited 23 adults with chronic SCI (7/2021-2/2023). In total, 18 participants started the study and completed all study components, including the 6-week follow-up. Twelve participants completed the 1-year follow-up assessment. Feasibility was demonstrated through participants' willingness to participate, adherence, and acceptability of the study. Mean age of the 18 participants was 60 ± 12 years, and they were 15 ± 11 years post-SCI with the highest baseline neuropathic pain of 7.94 ± 2.33, which was reduced to 4.17 ± 3.07 after 12 weeks of Qigong practice (Cohen's d = 1.75). This pain relief remained at 6-week and 1-year follow-ups. Participants reported reduced spasm frequency (change score 1.17 ± 1.20, d = 0.98) and severity (0.72 ± 1.02, d = 0.71), reduced interference of neuropathic pain on mood (3.44 ± 2.53, d = 1.36), sleep (3.39 ± 2.40, d = 1.41), daily activities (3.17 ± 2.77, d = 1.14), greater ability to perform functional activities (6.68 ± 3.07, d = 2.18), and improved mood (2.33 ± 3.31, d = 0.70) after Qigong. Discussion: Remote Spring Forest Qigong's "Five Element Qigong Healing Movements" practice is feasible in adults with SCI-related neuropathic pain, with promising prolonged results of neuropathic pain relief and improvement in SCI-related symptoms after Qigong practice. Clinical trial registration: https://www.clinicaltrials.gov/ct2/show/NCT04917107, identifier NCT04917107.

Neuropathic Pain and Spinal Cord Injury: Management, Phenotypes, and Biomarkers

Chronic neuropathic pain after a spinal cord injury (SCI) continues to be a complex condition that is difficult to manage due to multiple underlying pathophysiological mechanisms and the association with psychosocial factors. Determining the individual contribution of each of these factors is currently not a realistic goal; however, focusing on the primary mechanisms may be more feasible. One approach used to uncover underlying mechanisms includes phenotyping using pain symptoms and somatosensory function. However, this approach does not consider cognitive and psychosocial mechanisms that may also significantly contribute to the pain experience and impact treatment outcomes. Indeed, clinical experience supports that a combination of self-management, non-pharmacological, and pharmacological approaches is needed to optimally manage pain in this population. This article will provide a broad updated summary integrating the clinical aspects of SCI-related neuropathic pain, potential pain mechanisms, evidence-based treatment recommendations, neuropathic pain phenotypes and brain biomarkers, psychosocial factors, and progress regarding how defining neuropathic pain phenotypes and other surrogate measures in the neuropathic pain field may lead to targeted treatments for neuropathic pain after SCI.

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.

Prescribing patterns for treating common complications of spinal cord injury

OBJECTIVE

The purpose of this study was to find the most and least commonly prescribed medications for treating secondary health complications associated with spinal cord injury (SCI); and determine overall polypharmacy rates and risk factors associated with it.

DESIGN

Observational design, cross-sectional analysis.

SETTING

Community; Canada.

PARTICIPANTS

Individuals with spinal cord injury (n = 108).

RESULTS

A total of 515 prescriptions were issued to the sample comprising 213 different medications to treat 10 SCI-related complications. Forty-five (45%) participants were prescribed >5 medications concurrently. No associations were found between the number of drugs taken and age, sex, level of injury, completeness of injury, time since injury, or cause of injury. The most commonly treated complications included pain (56.5%), muscle spasms (54%) and urinary tract infections (43%). Anti-convulsants (pregabalin, gabapentin), anti-spasmodics (baclofen, diazepam) and nitrofurantoins (Macrobid) were the most commonly prescribed medications to treat each of the three conditions, respectively. Thirty five percent of the total sample received a combination of two or more analgesics including fourth-line agents in the opiate class (hydromorphone, hydrocodone and morphine). Similarly, some participants were prescribed general muscle relaxants and cephalosporins for treatment of muscle spasms and urinary tract infections, respectively, that are generally not recommended in SCI patients. We compare these prescribing patterns with the available clinical practice guidelines and highlight areas where the prescriptions fall outside the recommended clinical practice while considering the complexity of medication management in SCI.

CONCLUSION

Medication management in SCI is complex. Tools are required that enable prescribers to choose evidence-based medical regimens and deprescribe potentially inappropriate medications for their patients with SCI.

Pain and pain management experiences following spinal cord injury - a mixed methods study of Australian community-dwelling adults

PURPOSE

There is a high prevalence of persistent pain following SCI yet insights into its impact and the quality of pain care are limited. We aimed to explore, in-depth, the problem of persistent pain in Australian community-dwelling adults with a spinal cord injury (SCI). Our objectives were to investigate (i) how individuals experience persistent pain, (ii) how they experience pain care and (iii) the concordance between clinical practice guidelines for managing pain and reported care practices.

METHODS

We conducted a mixed-methods convergent parallel study. Adults with SCI and persistent pain completed a survey (n = 43); a subset of participants completed interviews (n = 10). We analysed the data from each method separately and then integrated the findings.

RESULTS

Results indicated that the life impact of persistent pain is variable but it can be more disabling than physical impairments and compound a sense of isolation and despair. Community-based management was reported to predominantly have a pharmacological focus, with occurrences of opioid misuse apparent in the data. Access to expert, comprehensive and individualised care was frequently reported as inadequate.

CONCLUSION

While some people with SCI and persistent pain can effectively self-manage their pain, for others the impact on quality of life is profound and complex care needs are commonly unmet.IMPLICATIONS FOR REHABILITATIONPersistent pain is a common consequence of SCI and profoundly impacts quality of life.Complex pain care needs are commonly unmet.Individuals require regular, comprehensive, biopsychosocial assessment.The effectiveness of pain management strategies must be monitored on an ongoing basis.Opportunities for personal self-management support must be available long-term.

Developing spinal cord injury physiotherapy clinical practice guidelines: a qualitative study to determine how physiotherapists and people living with spinal cord injury use evidence

STUDY DESIGN

Generic qualitative design.

OBJECTIVES

Australian and New Zealand SCI physiotherapists are developing clinical practice guidelines for the physiotherapy management of people living with spinal cord injury. To guide the development of the guidelines it was important to understand how physiotherapists and people living with spinal cord injury use evidence to choose interventions and the potential barriers and facilitators to the uptake of the clinical practice guidelines.

SETTING

Spinal Cord Injury Centres in Sydney, Australia and New Zealand.

METHODS

Focus groups and interviews with physiotherapists and people living with spinal cord injury were recorded, transcribed, and subjected to thematic analysis.

RESULTS

A total of 75 participants took part in the study, 45 physiotherapists and 30 people living with spinal cord injury. Three main themes were identified from the data: (1) Types and sources of evidence that influence treatment choices, (2) the many factors determining treatment choices, and (3) ways in which clinical practice guidelines could influence treatment.

CONCLUSIONS

Clinical practice guidelines have the potential to reduce the barriers identified by physiotherapists in accessing and interpreting research evidence on interventions for people living with spinal cord injury. Supported implementation of guidelines is required to demonstrate their benefit and encourage physiotherapists to factor in evidence when balancing the multiple factors influencing choice of physiotherapy intervention.

Prevalence and Determinants of Pain in Spinal Cord Injury During Initial Inpatient Rehabilitation: Data From the Dutch Spinal Cord Injury Database

OBJECTIVE

To describe the prevalence and characteristics of spinal cord injury (SCI)-related pain during initial inpatient rehabilitation and to investigate relationships with demographic and lesion characteristics.

DESIGN

Cohort during inpatient rehabilitation.

SETTING

Eight specialized SCI rehabilitation centers in the Netherlands.

PARTICIPANTS

Patients with newly acquired SCI admitted for inpatient rehabilitation between November 2013 and August 2019 (N=1432).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Presence of pain at admission and discharge. Logistic regression analyses were used to study the prevalence of pain related to sex, age, etiology, completeness, and level of injury.

RESULTS

Data from 1432 patients were available. Of these patients 64.6% were male, mean age was 56.8 years, 59.9% had a nontraumatic SCI, 63.9% were classified as American Spinal Cord Injury Association Impairment Scale (AIS) D and 56.5% had paraplegia. Prevalence of pain was 61.2% at admission (40.6% nociceptive pain [NocP], 30.2% neuropathic pain [NeuP], 5.4% other pain) and 51.5% at discharge (26.0% NocP, 31.4% NeuP, 5.7% other pain). Having NocP at admission was associated with traumatic SCI. AIS B had a lower risk of NocP than AIS D at admission. Having NocP at discharge was associated with female sex and traumatic SCI. AIS C had a lower risk of NocP at discharge than AIS D. Having NeuP at admission was associated with female sex. Having NeuP at discharge was associated with female sex, age younger than 65 years vs age older than 75 years and tetraplegia.

CONCLUSIONS

SCI-related pain is highly prevalent during inpatient rehabilitation. Prevalence of NocP decreased during inpatient rehabilitation, and prevalence of NeuP stayed the same. Different patient and lesion characteristics were related to the presence of SCI-related pain. Healthcare professionals should be aware of these differences in screening patients on presence and development of pain during inpatient rehabilitation.

Optogenetics: Emerging strategies for neuropathic pain treatment

Neuropathic pain (NP) is a chronic health condition that presents a significant burden on patients, society, and even healthcare systems. However, in recent years, an emerging field in the treatment of neuropathic pain - optogenetic technology has dawned, heralding a new era in the field of medicine, and which has brought with it unlimited possibilities for studying the mechanism of NP and the treatment of research. Optogenetics is a new and growing field that uses the combination of light and molecular genetics for the first time ever. This rare combination is used to control the activity of living cells by expressing photosensitive proteins to visualize signaling events and manipulate cell activity. The treatments for NP are limited and have hardly achieved the desirable efficacy. NP differs from other types of pain, such as nociceptive pain, in that the treatments for NP are far more complex and highly challenging for clinical practice. This review presents the background of optogenetics, current applications in various fields, and the findings of optogenetics in NP. It also elaborates on the basic concepts of neuropathy, therapeutic applications, and the potential of optogenetics from the bench to the bedside in the near future.

Feasibility of gabapentin as an intervention for neurorecovery after an acute spinal cord injury: Protocol

Introduction

This protocol is describing the first ever prospective, mock-efficacy, dose exploration trial design testing the feasibility of administering gabapentin in the acute setting as an intervention for neurorecovery. Gabapentin is an FDA-approved medication for treating seizures and postherpetic neuralgia and is used broadly off-label for neuropathic pain management for many conditions, including spinal cord injury. Emerging data suggests that when given early after spinal cord injury onset and in low-medium doses, gabapentin may have properties that promote recovery of neurological function. The objective of this trial is to assess the feasibility of conducting an efficacy trial in which gabapentin is started early after injury, is restricted in its dose, and is not used for pain management.

Methods and analysis

Forty-two people aged 18 years or older with any level and any severity of spinal cord injury induced by a trauma will be enrolled, randomized, and have the first dose of study medication by 120 h post-injury onset. Participants will be randomly assigned to one of three groups: 600, 1,800 mg/day gabapentin, or placebo. Study medication will be given for a 90-day duration. Blinded assessments will be obtained at 7 days post-injury (baseline), 30 days post-injury (interim), after the 90-day treatment duration/approximately 3 months post-injury (end of treatment), and at 6 months post-injury (end of study). The key analysis parameters will evaluate feasibility of recruitment of target population, delivery of drug treatment protocol, maintenance of blinding, and retention of participants.

Discussion

Outputs from this trial will inform research and clinical practice on the effects of manipulating gabapentin for non-pain management purposes in the acute setting and will guide the development of a properly powered efficacy trial of gabapentin as an intervention for neurorecovery in spinal cord injury.

Ethics and dissemination

The study was approved by the MetroHealth Institutional Review Board (IRB21-00609) and registered at clinicaltrials.gov prior to enrolling any participants. Dissemination will include peer-reviewed publications, presentations at professional conferences and in the community, and through other healthcare and public venues.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT05302999; protocol version 1.1 approved 05/23/2022.

Trial funding

National Institute on Disability, Independent Living and Rehabilitation Research.

Spinal cord stimulation for neuropathic pain following traumatic spinal cord injury: a case report

INTRODUCTION

Neuropathic pain is a common complication of spinal cord injury (SCI), and is notoriously difficult to adequately treat. Gunshot wounds (GSW) near the spinal cord may cause intractable chronic pain through spinal/nerve root transection, or reactive tissue formation resulting in nerve root compression from retained bullet fragments (RBF).

CASE PRESENTATION

This case report describes a 30-year-old man with a T12 AIS B incomplete spinal cord injury with paraplegia secondary to multiple GSW who presented with severe bilateral lower extremity dysesthesias and muscle spasms. Symptoms failed to improve with oral antispasmodic medications. After being diagnosed with Complex regional pain syndrome (CRPS) type I secondary to an SCI via GSW, he underwent a spinal cord stimulator (SCS) trial, which improved his symptoms by greater than 80%.

DISCUSSION

Neuropathic pain refractory to conservative treatment may benefit from SCS. Effects of therapy go beyond gate-theory in SCI patients, and may benefit patients at the cellular and molecular level. Our case demonstrates the effectiveness of SCS treatment in a patient who developed CRPS type 1 after GSW resulting in SCI.

A scoping review on the effect of cannabis on pain intensity in people with spinal cord injury

CONTEXT

This scoping review examines the current research on the effect of cannabis upon pain intensity in spinal cord injury (SCI) pain. Chronic pain is a significant secondary condition following SCI, and traditional treatments (e.g. opioids, NSAIDs) are often criticized for providing inadequate relief. As a result, there is increasing interest in and use of cannabis and cannabinoid-based medications as an alternative means of pain control.

OBJECTIVE

The purpose of this review was to examine the scientific evidence on the effect of cannabis/cannabinoids upon pain intensity in SCI by mapping the current literature.

METHODS

Two hundred and fifty-two studies were identified by searching electronic databases for articles published through February 2020. In addition, reviewers scanned the reference lists of identified articles and examined clinicaltrials.gov for unpublished data in this area. Title, abstract, and full-text reviews were completed by two independent reviewers. Data extraction was performed by a single reviewer and verified by a second reviewer.

RESULTS

Six articles covering five treatment studies were included. Studies yielded mixed findings likely due to large variability in methodology, including lack of standardized dosing paradigms, modes of use, and duration of trial.

CONCLUSIONS

The current quality and level of evidence is insufficient to draw reliable conclusions of the efficacy of cannabis upon SCI-related pain itensity. We identify specific limitations of past studies and present guidelines for future research.Trial registration: ClinicalTrials.gov identifier: Nct01606202..

Should Non-Pharmacological and Non-Surgical Interventions be Used to Manage Neuropathic Pain in Adults With Spinal Cord Injury? - A Systematic Review

Spinal Cord Injury (SCI) results in a permanent or temporary alteration of the motor, sensory and/or autonomic functions, frequently leading to neuropathic pain. To deal with this comorbidity, several non-pharmacological and non-surgical (NP-NS) interventions have been developed. However, their efficacy is still uncertain. The aim of this study was to systematically synthetize the available evidence assessing the efficacy of NP-NS interventions for treating neuropathic pain in people with SCI. Thus, an electronic search was conducted in five databases (Pubmed, Scopus, Cochrane Central, Web of Science and EBSCO) and trials registry databases, in addition to a manual search strategy to retrieve additional records. The review included randomized controlled trials with adults with SCI, in any stage of the condition. Data on the efficacy of the interventions was narratively synthetized. Once the research was completed, of 4853 identified references, 24 were included with a total of 653 participants with SCI and neuropathic pain, mostly male and with paraplegia. These studies investigated the effect of 13 types of NP-NS interventions with different protocols and methodological limitations. Seven different assessment scales were analyzed, with neuropathic pain being the primary outcome in 21 studies. Such high heterogeneity impaired the conduction of meta-analysis for any of the interventions. Although promising results were found regarding analgesic effect of NP-NS on neuropathic pain in people with SCI, it is not yet possible to safely state that these interventions are in fact effective. Further studies with homogeneous protocols and methodological quality are still needed. PERSPECTIVE: This article presents a review of existing studies on the effectiveness of NP-NS interventions in neuropathic pain in SCI. This synthesis could potentially alert and motivate clinicians to develop studies on this topic, so that interventions can be objectively evaluated and recommendations for an evidence-based practice be created.

Case report: The feasibility of rTMS with intrathecal baclofen pump for the treatment of unresolved neuropathic pain following spinal cord injury

The main objective of this study was to assess the efficacy and safety of 10 Hz repetitive transcranial magnetic stimulation (rTMS) for the treatment of unresolved neuropathic pain in an individual with spinal cord injury and an intrathecal baclofen pump. A 62-year-old male presented with drug resistant neuropathic pain as a result of a complete spinal cord lesion at T8 level. Pain was classified into four types: pressure pain in the left foot, burning pain in buttocks, burning pain in sternum, and electrical attacks in the trunk. The treatment period involved 6 weeks of rTMS stimulation performed 5 days per week, a 6-week follow up period with no stimulation, and an 8-week top up session period which began 5-weeks after the end of the follow up period. 2004 pulses were delivered at 10Hz over the right-hand representation of the left primary motor cortex at 80% resting motor threshold during each session. Assessments were based on the numerical rating scale (NRS), neuropathic pain scale (NPS), Hamilton Depression and Anxiety rating scales. Following the treatment period there was a 30, 13, and 29% reduction in sternum, buttocks, and left foot pain respectively, as reported by the NRS. During this time, electrical attacks were abolished following the third week of treatment. These changes corresponded to a 38% decrease in NPS scores and a 65 and 25% reduction in anxiety and depressions scores respectively. The changes in sternum, buttocks, and left foot pain reported on the NRS persisted for 1 week following treatment. Top up sessions delivered 11 weeks after the end of the treatment period were unsuccessful in reducing pain to the level achieved during the treatment period. A 13% reduction in NPS was seen during these 8-weeks. Anxiety and depression scores decreased 78 and 67% respectively. The frequency of electrical attacks was zero during this time. rTMS stimulation delivered throughout this study did not cause any interference with the functioning of the intrathecal baclofen pump. This case study illustrates that rTMS may be effective at reducing drug resistant neuropathic pain with certain pain types exhibiting greater propensity for change.

Is transcranial magnetic stimulation as treatment for neuropathic pain in patients with spinal cord injury efficient? A systematic review

BACKGROUND AND PURPOSE

Neuropathic pain is a clinically relevant complication in individuals with spinal cord injury (SCI). Pharmacological pain treatment is often insufficient and leads to undesirable side effects. Thus, alternative therapeutic approaches such as repetitive transcranial magnetic stimulation (rTMS) are of critical importance. We aimed to evaluate the effectiveness of rTMS in neuropathic pain secondary to SCI.

METHODS

We conducted a systematic review using the PubMed/MEDLINE, EMBASE, and PsycInfo (via OVID) database up April 2021. Only randomized controlled trials were included. Results regarding the pain intensity scores were pooled using a random-effects model.

RESULTS

The search identified a total of 203 potential articles. Of these, eight randomized controlled trials (RCTs) met the eligibility criteria for qualitative synthesis providing the total data of 141 patients. All studies applied high-frequency rTMS. In seven studies, rTMS was applied over the motor cortex, and in one study over the left dorsolateral prefrontal cortex. Five studies reported a significant improvement in baseline pain scores after treatment, and three studies found a significant difference between sham vs. non-sham stimulation at any time. Six RCTs were included in the quantitative synthesis and showed a significant overall reduction of pain intensity in the rTMS groups compared with the sham groups (mean difference - 0.81, 95%CI - 1.45 to - 0.17).

CONCLUSIONS

Our findings indicate that high-frequency rTMS of the primary motor cortex and left dorsolateral prefrontal cortex might be promising stimulation targets for neuropathic pain in SCI.

miR-338-5p Levels and Cigarette Smoking are Associated With Neuropathic Pain Severity in Individuals With Spinal Cord Injury: Preliminary Findings From a Genome-Wide microRNA Expression Profiling Screen

OBJECTIVE

To identify microRNA biomarkers and clinical factors associated with neuropathic pain after spinal cord injury.

DESIGN

Cross-sectional, secondary analysis of baseline data collected from ongoing clinical studies. Using a genome-wide microRNA screening approach, we studied differential microRNA expression in serum from 43 adults with spinal cord injury enrolled in ongoing clinical studies. Least squares regression was used to identify associations between microRNA expression, clinical factors, and neuropathic pain severity.

SETTING

Community-dwelling individuals with spinal cord injury.

PARTICIPANTS

Participants (N=43) were at least 18 years old with spinal cord injury, with 28 reporting neuropathic pain and 15 reporting no neuropathic pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Pain presence, type, and intensity were assessed with the International Spinal Cord Injury Pain Basic Data Set. Serum microRNA normalized deep sequencing counts were quantified from blood samples. Participant demographic factors, injury characteristics, medication use, and health habits were collected via questionnaire.

RESULTS

miR-338-5p expression and history of cigarette smoking were associated with and explained 37% of the variance in neuropathic pain severity (R2=0.37, F2,18=5.31, P=.02) independent of other clinical factors. No association was identified between miR-338-5p levels and nociceptive pain severity.

CONCLUSIONS

Our findings suggest that miR-338-5p and cigarette smoking may both play a role in the development or maintenance of neuropathic pain after spinal cord injury. While additional work is needed to confirm these findings, validated target analysis suggests a neuroprotective role of miR-338-5p in modulating neuroinflammation and neuronal apoptosis and that its downregulation may result in maladaptive neuroplastic mechanisms contributing to neuropathic pain after spinal cord injury.

Non-opioid pharmacologic treatment of chronic spinal cord injury-related pain

Purpose: Spinal cord injury-related pain is often a severe debilitating condition that adversely affects the patient's physical health, psychological wellbeing and quality of life. Opioid medications have historically been prescribed to this population with great frequency. As opioid abuse disorder becomes an ever-worsening public health issue, more attention must be placed upon non-opioid options. This paper reviews non-opioid medications to be considered when treating spinal cord injury-related pain. The pertinent literature is reviewed, and the advantages and pitfalls of various medication options are discussed in the complicated context of the individual with a spinal cord injury.Methods: Peer-reviewed journal articles and medication package insert data are reviewed.Results:. The non-opioid medications with the greatest evidence for efficacy in the treatment of chronic spinal cord injury-related pain are drawn from the antiepileptic drug and antidepressant categories though the specific selection must be nuanced to the particular individual patient. More research is required to understand the role of calcitonin, lithium, and marijuana in treating spinal cord injury-related pain.Conclusions: The complex clinical situation of each individual patient must be weighed against the risks and benefits of each medication, as reviewed in this paper, to determine the ideal treatment strategy for chronic spinal cord injury-related pain.

The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update

STUDY DESIGN

Clinical practice guidelines.

OBJECTIVES

The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).

SETTING

The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada.

METHODS

The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.

RESULTS

The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made.

CONCLUSIONS

The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice.

The Impact of Sub-maximal Exercise on Neuropathic Pain, Inflammation, and Affect Among Adults With Spinal Cord Injury: A Pilot Study

Introduction: Persons with spinal cord injury (SCI) often report high levels of neuropathic pain (NP) and poor well-being, which may result from increased inflammation. This study examined the impact of sub-maximal aerobic exercise on NP, inflammation and psychological affect among adults with SCI. Methods: Eight active adults with tetraplegia (n-4, AIS A-C) and paraplegia (n = 4, AIS A-C) performed 30-min of arm-crank aerobic exercise and reported their ratings of perceived exertion (RPE) each minute. Measures of NP, affect, and inflammatory cytokines (IL-6, IL-10, IL-1ra, TNF-α) were taken pre-(T₀), immediately post-(T₁), and 90-min post-exercise (T₂). Results: NP decreased between T₀ and T₁ for tetraplegics (-60%, d = 0.47; CI = -0.32, 2.02) and paraplegics (-16%, d = 0.15; CI = -0.30, 0.90). Correlations between change in cytokines and change in NP were medium-to large for tetraplegics (rs ranged from -0.820 to 0.965) and paraplegics (rs ranged from -0.598 to 0.833). However, the pattern of correlations between change in cytokines and affect was inconsistent between groups. Lower baseline levels of IL-1ra predicted greater decreases in NP immediately post-exercise (r = 0.83, p = 0.01). Conclusion: Sub-maximal exercise can positively impact NP for some persons with SCI. Further experimental research should identify the optimal exercise intensity to reduce NP for persons with SCI, in addition to understanding biomarkers which may predict changes in NP. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03955523.

Utilization of Complementary and Integrative Health Care by People With Spinal Cord Injury in the Spinal Cord Injury Model Systems: A Descriptive Study

OBJECTIVE

To characterize the use of complementary and integrative health care (CIH) by people with spinal cord injury.

DESIGN

Cross-sectional self-report study.

SETTING

Participants were recruited from 5 Spinal Cord Injury Model Systems (SCIMS) centers across the United States.

INTERVENTIONS

Not applicable.

PARTICIPANTS

A total of 411 persons enrolled in the SCIMS completing their SCIMS follow-up interview between January 2017 and July 2019 (N = 411).

MAIN OUTCOME MEASURES

Participants completed a survey developed for this study that included questions about types of CIH currently and previously used, reasons for current and previous use, reasons for discontinuing use of CIH, and reasons for never using CIH since injury.

RESULTS

Of the 411 respondents, 80.3% were current or previous users of CIH; 19.7% had not used CIH since injury. The most commonly used current types of CIH were multivitamins (40.0%) and massage (32.6%), whereas the most common previously used type of CIH was acupuncture (33.9%). General health and wellness (61.4%) and pain (31.2%) were the most common reasons for using CIH. The primary reason for discontinuing CIH was that it was not helpful (42.1%). The primary reason for not using CIH since injury was not knowing what options are available (40.7%).

CONCLUSIONS

These results point to the importance for rehabilitation clinicians to be aware that their patients may be using 1 or more CIH approaches. Providers should be open to starting a dialogue to ensure the health and safety of their patients because there is limited information on safety and efficacy of CIH approaches in this population. These results also set the stage for further analysis of this data set to increase our knowledge in this area.

Barriers and Facilitators to Optimal Neuropathic Pain Management: SCI Consumer, Significant Other, and Health Care Provider Perspectives

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.

The Efficacy, Adverse Events & Withdrawal Rates of the Pharmacological Management of Chronic Spinal Cord Injury Pain: A Systematic Review & Meta-Analysis

OBJECTIVE

To establish the efficacy of medications, incidence of adverse events (AE) and withdrawal rates (WR) of the pharmacological management of chronic spinal cord injury (SCI) pain.

METHODOLOGY

PubMed, MEDLINE, Embase, CINAHL, Web of Science, CENTRAL and PsycINFO were searched (November 2017) and updated (January 2020). Two independent review authors screened and identified papers for inclusion.

RESULTS

Twenty-one studies met inclusion for efficacy analysis and 17 for AEs and WR analysis; no additional paper were included from the up dated 2020 search. Treatments were divided into 6 categories: anticonvulsants (n = 6), antidepressants (n = 3), analgesics (n = 8), anti-spasticity (n = 2), cannabinoids (n = 1) and other (n = 2). Trials of anticonvulsants, antidepressants, and cannabinoids included long-term follow-up trials (2 weeks- 4 months), and analgesics, anti-spasticity, among others were short term trials (0-2 days). Effectiveness for NP was found for Pregabalin (3/3 studies) and Lidocaine (2/3 studies). Studies using Ketamine also reported effectiveness (2/2) but the quality of these papers was rated as poor. Most frequently reported AEs included dizziness, dry mouth, nausea and constipation. Pregabalin had a higher risk of somnolence (RR 3.15, 95% CI 2.00-4.98) and dizziness (RR 2.9, 95% CI 1.58-5.30). Ketamine had a higher risk of reduced vision (RR 9.00, 95% CI 0.05-146.11), dizziness (RR 8.33, 95% CI 1.73-40.10) and somnolence (RR 7.00, 95% CI 1.73-40.1). WRs ranged from: 18.4% (antidepressants), 0-30% (anticonvulsants), 0-10% (anti-spasticity), 0-48% (analgesics), 28.6% (cannabinoids) and 0-22.2% (other).

CONCLUSION

Pregabalin was found to be effective for NP versus placebo. Cannabinoids was ineffective for NP. AEs are a common cause for withdrawal. The nature of AEs was poorly reported and should be improved in future RCT's.

Prevalence of prescribed opioid claims among persons with nontraumatic spinal cord dysfunction in Ontario, Canada: a population-based retrospective cohort study

STUDY DESIGN

Cohort study.

OBJECTIVE

To determine the prevalence and to identify predictors of prescription opioid use among persons with nontraumatic spinal cord dysfunction within 1 year after discharge from inpatient rehabilitation.

SETTING

Ontario, Canada.

METHODS

We conducted a retrospective cohort study using administrative data to determine predictors of receiving prescription opioids during the 1 year after discharge from inpatient rehabilitation among persons with nontraumatic spinal cord dysfunction between April 1, 2004 and March 31, 2015. We modeled the outcome using a Poisson multivariable regression and reported relative risks with 95% confidence intervals.

RESULTS

We identified 3468 individuals with nontraumatic spinal cord dysfunction (50% male) with 67% who were aged ≥66. Over half of the cohort (60%) received opioids during the observation period. Older adults (≥66 years old) were significantly more likely to experience comorbidities (p < 0.05) but less likely to be dispensed opioids following rehabilitation discharge. Being female, previous opioid use before rehabilitation, experiencing lower continuity of care, increasing comorbidity level, low functional status, and having a previous diagnosis of osteoarthritis or mental illness were significant risk factors for receiving opioids after discharge, as shown in a multivariable analysis. Increasing length of rehabilitation stay and higher income were protective against opioid receipt after discharge.

CONCLUSION

Many individuals with nontraumatic spinal cord dysfunction in Ontario are prescribed opioids after discharge from inpatient rehabilitation. This may be problematic due to the number of severe complications that may arise from opioid use and their use in this population warrants future research.

Evaluation of the quality of published SCI clinical practice guidelines using the AGREE II instrument: Results from Can-SCIP expert panel

INTRODUCTION

Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care.

METHODS

Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80).

CONCLUSION

There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.

Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview

INTRODUCTION

Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual's sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual's care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process.

METHODS

The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool.

RESULTS

The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo.

CONCLUSION

The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.

Preliminary study of analgesic effect of bumetanide on neuropathic pain in patients with spinal cord injury

BACKGROUND/OBJECTIVE

The current study evaluated the analgesic effects of bumetanide as an adjunctive treatment in managing neuropathic pain following spinal cord injury. The peripheral expression level of Na-K-Cl-cotransporter-1 (NKCC1) and K-Cl-cotransporter-2 (KCC2) genes in polymorphonuclear lymphocytes (PMLs) assessed as a possible biomarker indicating central underlying mechanisms.

METHODS

This open-label, single-arm, pilot trial of bumetanide (2 mg/day) is an add-on treatment conducted in 14 SCI patients for 19 weeks. The whole duration consisted of three phases: pre-treatment (1 month), titration (3 weeks), and active treatment (4 months). Ultimately, nine patients completed the study. The primary outcome variables were the endpoint pain score measured by the numeric rating scale (NRS), and the short-form McGill Pain Questionnaire. Secondary endpoints included the Short-Form Health Survey that measures the quality of life. Blood samples were collected and used for determining the expression of NKCC1 and KCC2 genes in transcription and translation levels.

RESULTS

Bumetanide treatment significantly reduced average pain intensity according to the NRS and the short form of the McGill Pain Questionnaire scores. The baseline expression of KCC2 protein was low between groups and increased significantly following treatment (P < 0.05). Through the current study, pain improvement accompanied by the more significant mean change from the baseline for the overall quality of life.

CONCLUSION

These data might be a piece of preliminary evidence for the analgesic effect of bumetanide on neuropathic pain and could support the potential role of the upregulation of KCC2 protein and involvement of GABAergic disinhibition in producing neuropathic pain.

Pharmacological treatment of central neuropathic pain: consensus of the Brazilian Academy of Neurology

ABSTRACT Background: Central neuropathic pain (CNP) is often refractory to available therapeutic strategies and there are few evidence-based treatment options. Many patients with neuropathic pain are not diagnosed or treated properly. Thus, consensus-based recommendations, adapted to the available drugs in the country, are necessary to guide clinical decisions. Objective: To develop recommendations for the treatment of CNP in Brazil. Methods: Systematic review, meta-analysis, and specialists opinions considering efficacy, adverse events profile, cost, and drug availability in public health. Results: Forty-four studies on CNP treatment were found, 20 were included in the qualitative analysis, and 15 in the quantitative analysis. Medications were classified as first-, second-, and third-line treatment based on systematic review, meta-analysis, and expert opinion. As first-line treatment, gabapentin, duloxetine, and tricyclic antidepressants were included. As second-line, venlafaxine, pregabalin for CND secondary to spinal cord injury, lamotrigine for CNP after stroke, and, in association with first-line drugs, weak opioids, in particular tramadol. For refractory patients, strong opioids (methadone and oxycodone), cannabidiol/delta-9-tetrahydrocannabinol, were classified as third-line of treatment, in combination with first or second-line drugs and, for central nervous system (CNS) in multiple sclerosis, dronabinol. Conclusions: Studies that address the treatment of CNS are scarce and heterogeneous, and a significant part of the recommendations is based on experts opinions. The CNP approach must be individualized, taking into account the availability of medication, the profile of adverse effects, including addiction risk, and patients' comorbidities.

Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study

OBJECTIVES

To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use.

DESIGN

Retrospective cohort study using population-level administrative data.

SETTING

Ontario, Canada.

PARTICIPANTS

Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period).

RESULTS

A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity.

CONCLUSIONS

A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.

Neuropathic pain in spinal cord injury: topical analgesics as a possible treatment

STUDY DESIGN

Review of the literature and semi-structured interviews.

OBJECTIVE

To explore the possible use of topical analgesics for the treatment of neuropathic pain (NP) in spinal cord injury (SCI).

SETTING

Institute for Neuropathic Pain, Soest, The Netherlands.

METHODS

A review was performed of studies on topical analgesics for SCI-related NP published up to May 2019. In addition, eight persons with SCI-related NP who were treated with topical analgesics were interviewed in a semi-structured interview on their experience with topical analgesics.

RESULTS

Seven studies (five case reports and two case series) were found that evaluated the use of topical analgesics for SCI-related NP. None of the studies used a control treatment. Topical analgesics included baclofen, ketamine, lidocaine, capsaicin, and isosorbide dinitrate. All studies reported a decrease in NP over time. Persons interviewed were 49-72 years of age and all but one had an incomplete SCI. They used topical agents containing phenytoin, amitriptyline, baclofen, ketamine or loperamide. All showed a decrease in pain of at least 3 points on the 11-point numeric rating scale during this treatment.

DISCUSSION/CONCLUSIONS

Evidence on the use of topical analgesics in SCI is scarce. Case reports, case series and interviews suggest that the use of topical analgesics can be beneficial in treating SCI-related NP. Placebo-controlled studies are required to investigate the effect of topical analgesics on SCI-related NP.

A pragmatic randomized controlled trial testing the effects of the international scientific SCI exercise guidelines on SCI chronic pain: protocol for the EPIC-SCI trial

STUDY DESIGN

Protocol for a pragmatic randomized controlled trial (the Exercise guideline Promotion and Implementation in Chronic SCI [EPIC-SCI] Trial).

PRIMARY OBJECTIVES

To test if home-/community-based exercise, prescribed according to the international SCI exercise guidelines, significantly reduces chronic bodily pain in adults with SCI.

SECONDARY OBJECTIVES

To investigate: (1) the effects of exercise on musculoskeletal and neuropathic chronic pain; (2) if reduced inflammation and increased descending inhibitory control are viable pathways by which exercise reduces pain; (3) the effects of chronic pain reductions on subjective well-being; and (4) efficiency of a home-/community-based exercise intervention.

SETTING

Exercise in home-/community-based settings; assessments in university-based laboratories in British Columbia, Canada.

METHOD

Eighty-four adults with chronic SCI, reporting chronic musculoskeletal or neuropathic pain, and not meeting the current SCI exercise guidelines, will be recruited and randomized to a 6-month Exercise or Wait-List Control condition. Exercise will occur in home/community settings and will be supported through behavioral counseling. All measures will be taken at baseline, 3-months and 6-months. Analyses will consist of linear mixed effect models, multiple regression analyses and a cost-utility analysis. The economic evaluation will examine the incremental costs and health benefits generated by the intervention compared with usual care.

ETHICS AND DISSEMINATION

The University of British Columbia Clinical Research Ethics Board approved the protocol (#H19-01650). Using an integrated knowledge translation approach, stakeholders will be engaged throughout the trial and will co-create and disseminate evidence-based recommendations and messages regarding the use of exercise to manage SCI chronic pain.

Cannabinoids and an anti-inflammatory diet for the treatment of neuropathic pain after spinal cord injury (The CATNP Study): study protocol for a randomized controlled trial

STUDY DESIGN

Multicenter, randomized, double-blind, placebo controlled, clinical trial.

OBJECTIVE

The objective of this paper is to evaluate the effectiveness of cannabinoids and an anti-inflammatory diet, alone and in combination, for the management of neuropathic pain (NP) after spinal cord injury (SCI).

SETTING

Two Canadian SCI rehabilitation centers.

METHODS

A sample of 144 individuals with SCI will receive either an anti-inflammatory diet, cannabinoids or a placebo for 6 weeks. Following this, a combined effect of these treatments will be evaluated for a further 6 weeks. The primary outcome measure will be the change in NP as assessed by the numeric rating scale (NRS). Secondary outcomes will include changes in inflammation, mood, sleep, spasticity, cost-effectiveness, and function.

CONCLUSION

This study will assess the efficacy of an anti-inflammatory diet and cannabinoids (individually and in combination) for the treatment of NP following SCI. Results may reveal a cost-effective, side-effect free intervention strategy which could be utilized for the long-term management of NP following SCI.

Comparison of the use of opioids only and pregabalin add-on for the treatment of neuropathic pain in cervical myelopathy patients: a pilot trial

Among patients with cervical myelopathy who were diagnosed with neuropathic pain (NP) by the LANSS test, the study participants were randomly assigned to one of the two study groups. The participants in one study group received opioids only, while those in the other group received opioids and pregabalin. Thirty-nine patients were analyzed in the study (20 patients in the opioid-only group and 19 in the pregabalin add-on group). The LANSS, neck pain, and arm pain scores in the pregabalin add-on group improved significantly compared with those in the opioid-only group after the first 4 weeks (p = 0.005, 0.001 and 0.035, respectively), but there was no significant difference between the two groups during the next 4 weeks (p = 0.615, 0.377 and 0.716, respectively). There was no significant difference in the neck disability index and EuroQol-5Dimension scores after four weeks and eight weeks of follow-up. Adverse events were reported by four patients (20.0%) in the opioid-only group and five patients (26.3%) in the pregabalin add-on group (p = 0.716). However, over time, the occurrence of side effects and dropouts increased in the pregabalin add-on group. This exploratory pilot study suggests that pregabalin add-on treatment is more efficient than the use of opioids alone at the beginning of NP treatment in cervical myelopathy patients. However, prescribing pregabalin add-on treatment for more than four weeks should be done cautiously.

Management of the Patient with Chronic Spinal Cord Injury

Individuals with spinal cord injuries or disorders (SCI/D), whether of traumatic or nontraumatic cause, require multidisciplinary management by their care team to achieve optimal health outcomes. SCI/D is relatively rare in the general population and primary care providers (PCPs) may not have extensive experience managing people with these disorders. Spinal cord injuries, impair the body's autonomic and biomechanical performance by interrupting the communications to and from major bodily systems. This article provides a framework to help PCPs understand how these changes impact their patient's physiologic function and subsequent risks for health complications with guidance for initial treatment approaches.

A Primary Care Provider's Guide to Pain After Spinal Cord Injury: Screening and Management

Individuals with spinal cord injury (SCI) often experience chronic pain as a secondary complication. It can significantly impair mental health, sleep, mood, and overall quality of life. It is important for providers within a primary care setting to recognize the different types of pain such as nociceptive and neuropathic. Various assessment tools are available to guide proper classification and subsequent management. Providers need to have a good knowledge base, structure, and patient focus when managing care. Nonpharmacological interventions are just as important and should be explored prior to or along with pharmacological interventions. Treatment modalities such as physical therapy, exercise, acupuncture, and cognitive behavioral therapy should be tailored to the individual to the greatest extent possible. Gabapentin, pregabalin, and amitriptyline have been studied extensively and are the first-line pharmacological agents for neuropathic pain. It is important to involve patients as equal stakeholders in any pain intervention with adequate lifelong follow-up. The aim of this article is to offer an overview of pain assessment, information, patient interaction, and treatment options available. Although chronic pain has remained difficult to treat successfully, primary care providers can play an integral role in delivering evidence-based and patient-centered care for managing chronic pain among individuals with SCI.

Advances in the Rehabilitation of the Spinal Cord-Injured Patient: The Orthopaedic Surgeons' Perspective

Acute traumatic spinal cord injury is a devastating condition affecting 17,700 new patients per year in the United States alone. Typically, orthopaedic surgeons focus on managing the acute surgical aspects of care (eg, surgical spinal decompression and stabilization). However, in the care of these patients, being familiar with how to prognosticate neurologic recovery and manage secondary complications is extremely important. In addition, as an integral part of the multidisciplinary care team, the surgeon should have an awareness of contemporary rehabilitation approaches to maximize function and facilitate reintegration into the community. The purpose of this review article is to provide a surgeon's perspective on these aspects of spinal cord injury care.

Treatment of at-level spinal cord injury pain with botulinum toxin A

Study design

Randomized, double-blinded, placebo-controlled, cross-over study.

Objective

To explore whether botulinum toxin A (BoNTA) could be effective for treating at-level spinal cord injury (SCI) pain.

Setting

Outpatient SCI clinic, New York, USA.

Methods

Participants were randomized to receive subcutaneous injections of either placebo or BoNTA with follow-up (office visit, telephone, or e-mail) at 2, 4, 8, and 12 weeks to assess the magnitude of pain relief post injection. Crossover of participants was then performed. Those who received placebo received BoNTA, and vice versa, with follow-up at 2, 4, 8, and 12 weeks.

Results

Eight participants completed at least one of the two crossover study arms. Four completed both arms. The median age of the eight participants was 45 years (range 32-61 years) and 75% were male. All had traumatic, T1-L3 level, complete SCI. Although our data did not meet statistical significance, we noted a higher proportion of participants reporting a marked change in average pain intensity from baseline to 8 and 12 weeks post-BoNTA vs. post-placebo (33% vs. 0%). At 2 and 4 weeks post-BoNTA, almost all participants reported some degree of reduced pain, while the same was not seen post-placebo (83% vs. 0%).

Conclusion

The subcutaneous injection of BoNTA may be a feasible approach for the control of at-level SCI pain and is worthy of further study.

Sponsorship

The onabotulinumtoxinA (BOTOX) used in this study was provided by Allergan (Irvine, CA).

Critical Care Management of Acute Spinal Cord Injury-Part II: Intensive Care to Rehabilitation

Spinal cord injury is devastating to those affected due to the loss of motor and sensory function, and, in some cases, cardiovascular collapse, ventilatory failure, and bowel and bladder dysfunction. Primary trauma to the spinal cord is exacerbated by secondary insult from the inflammatory response to injury. Specialized intensive care of patients with acute spinal cord injury involves the management of multiple systems and incorporates evidence-based practices to reduce secondary injury to the spinal cord. Patients greatly benefit from early multidisciplinary rehabilitation for neurologic and functional recovery. Treatment of acute spinal cord injury may soon incorporate novel molecular agents currently undergoing clinical investigation to assist in neuroprotection and neuroregeneration.

An internet-delivered cognitive behavioural therapy pain management programme for spinal cord injury pain: A randomized controlled trial

BACKGROUND

Chronic pain is common after spinal cord injury (SCI) and dedicated SCI cognitive behavioural therapy pain management programmes (CBT-PMPs) have a growing evidence base to support their uptake clinically. The development of internet-delivered treatment options may overcome barriers to the access and uptake of centre-based programmes. This study examines such an approach on quality of lie (QoL), pain, mood and sleep.

METHODS

Adults with SCI pain (>3 months) were recruited and randomly assigned to the intervention or control group. The intervention comprised a six module CBT-PMP delivered once weekly. A blinded assessor determined changes in self-reported outcome measures post-intervention and at 3 months. Linear mixed models and effect sizes based on changes between groups were reported. Significance was set p < 0.05.

RESULTS

The recruitment rate was 32% (intervention n = 35, control n = 34), and the drop-out rate at 3 months was 26%. On average, participants accessed three (SD 2.1) of six modules. While no difference in QoL was reported, a significant group*time interaction was found for NRS of current pain (χ²  = 8.22, p = 0.016), worst pain (χ²  = 11.20, p = 0.004), and Brief Pain Inventory (interference) (χ²  = 6.924, p = 0.031). Moderate to large effect sizes favouring the intervention were demonstrated at each time point for the pain metrics (Cohen's d: 0.38-0.84). At 3-month follow-up, 48% of the intervention group rated themselves improved or very much improved (p < 0.05).

CONCLUSIONS

This study demonstrates the potential of an internet-delivered SCI specific CBT-PMP in reporting significant statistical and clinical benefit in pain intensity and interference. Strategies to improve engagement are needed.

Pulse article: opioid prescription for pain after spinal cord damage (SCD), differences from recommended guidelines, and a proposed algorithm for the use of opioids for pain after SCD

Study design

Online questionnaire of spinal cord injury (SCI) physicians.

Objectives

The objective of this study is to characterize the approach to opioid prescription for persons with spinal cord damage (SCD).

Setting

An international online questionnaire.

Methods

A survey was posted online and circulated among international societies within the field of SCI medicine from August to November 2018.

Results

One hundred and twenty-three physicians responded to the survey. Of these, 107 (92%) managed pain for persons with SCD. Most (82%) felt that opioid prescription was appropriate for uncontrolled acute pain, but fewer (67%) felt it was appropriate for chronic pain. Of those who felt opioids had a role in the treatment of neuropathic pain, 46% did not think there should be a specific upper limit of opioid dose. The majority (85%) would continue prescribing high doses (250 morphine milligram equivalent (MME) doses/day) if that dose were effective. Tramadol was the most common opioid prescribed first line.

Conclusion

Most physicians who responded to this survey prescribe opioids for intractable pain after SCD. A significant proportion of respondents believed that there should not be a specific upper limit of opioid dose prescribed if the drug is tolerated; this does not align with current recommendations. Most physicians do not feel influenced in their prescribing habits by regulatory bodies. If physicians decide to taper an opioid that is being tolerated well, it is most commonly related to a fear of the patient developing an opioid-use disorder. The authors propose an algorithm that may help align practice patterns with current recommended practice guidelines.

Pain profiles in a community dwelling population following spinal cord injury: a national survey

CONTEXT

While as many as 60% of patients with spinal cord injury (SCI) develop chronic pain, limited data currently exists on the prevalence and profile of pain post-SCI in community dwelling populations.

STUDY DESIGN

A cross-sectional population survey.

SETTING

Primary care.

PARTICIPANTS

Community dwelling adults with SCI.

METHODS

Following ethical approval members registered to a national SCI database (n=1,574) were surveyed. The survey included demographic and SCI characteristics items, the International Spinal Cord Injury Pain Basic Data Set (version 1) the Douleur Neuropathique 4 questionnaire (interview) and questions relating to health care utilisation. Data were entered into the Statistical Package for the Social Sciences (version 20) Significance was set P < 0.05 for between group comparisons.

RESULTS

In total 643 (41%) surveys were returned with 458 (71%) respondents experiencing pain in the previous week. Neuropathic pain (NP) was indicated in 236 (37%) of responses and nociceptive pain in 206 (32%) Common treatments for pain included medications n=347 (76%) massage n=133 (29%) and heat n=115 (25%). Respondents with NP reported higher pain intensities and increased healthcare service utilisation (P= < 0.001) when compared to those with nociceptive pain presentations. A higher proportion of females than males reported pain (P = 0.003) and NP (P = 0.001) and those unemployed presented with greater NP profiles compared with those in education or employment (P = 0.006).

CONCLUSION

Pain, in particular NP post SCI interferes with daily life, increases health service utilisation and remains refractory to current management strategies. Increased availability of multi-disciplinary pain management and further research into management strategies is warranted.

Survey on current treatments for pain after spinal cord damage

Study design

An online questionnaire.

Objectives

To assess the international spinal cord medicine and rehabilitation community's utilization of pharmacological and non-pharmacological treatments for spinal cord damage (SCD)-related pain and to determine whether approaches to SCD-related pain differ between developed and less developed nations.

Setting

An international collaboration of authors.

Methods

An on-line survey querying availability and utilization of a number of approaches to SCD-related pain was developed, distributed, and made available for 6 months. Responses were analyzed for the entire cohort and according to participants' descriptions of their home nations' economies.

Results

A total of 153 responses were submitted, mostly from developed nations. Nearly three quarters of subjects reported offering their patients with SCD narcotics; only 13% reported offering their patients with SCD medical cannabis. Subjects from developing countries were more likely than those from developed countries to prescribe buprenorphine (20.0% vs 15.6%; p = 0.001) and less likely to prescribe medical cannabis (0% vs 15.6%; p = 0.001) and acupuncture (4.0% vs 23.4%; p = 0.02).

Conclusions

Most spinal cord medicine clinicians employ a multimodal approach to pain. There are significant differences in utilization of pharmacologic and non-pharmacologic approach to SCD-related pain between clinicians from more and less developed countries.

Evaluating the effectiveness of antidepressant therapy adjuvant to gabapentin and pregabalin for treatment of SCI-related neuropathic pain

OBJECTIVE

To investigate if a combination of anticonvulsant and antidepressant, two primary therapies for neuropathic pain, is associated with improved pain control compared to individual therapy.

DESIGN

Prospective cohort study Setting: The University of Alabama at Birmingham Rehabilitation Center In-patient Program between 2012 and 2015.

PARTICIPANTS

Incident SCI cases, 19-65 years of age.

OUTCOMES

Bryce-Ragnarsson pain classification scheme and the Numerical Rating Scale Results: Twenty-nine eligible patients completed 6-month follow-up; their average age was 36.4 years, 89% were male, and 65% were white. Baseline characteristics were not different by therapy initiated (combination versus single). At 6 months follow-up, therapy initiated at baseline was not associated with level of pain in the past week (p=0.3145) or past 24 hours (p=0.4107). However, patients who remained on the same therapy reported lower levels of pain 30 minutes after waking (p=0.0235).

CONCLUSIONS

The initiation of a combination of anticonvulsant and antidepressant shortly after SCI was not associated with improved pain control at 6 months compared to individual therapy. Adherent patients reported lower levels of pain; further analysis is warranted to elucidate this association.

An examination of diurnal variations in neuropathic pain and affect, on exercise and non-exercise days, in adults with spinal cord injury

STUDY DESIGN

Case series.

OBJECTIVES

The temporal relationships between exercise, neuropathic pain and affect are not well understood. The purpose of this study was to utilize ecological momentary assessment to measure intra-individual diurnal variations in neuropathic pain and affect on exercise and non-exercise days. This study aimed to provide a deeper understanding of how neuropathic pain and affect change from pre- to post-exercise, and over time.

SETTING

Community.

METHODS

Six physically active men with SCI participated in a 6-day protocol (M age = 39.33 ± 8.24; 83.3% tetraplegics; years post injury = 6-17 years). Using their Smartphones, participants completed the Feeling Scale, Felt Arousal Scale, and Neuropathic Pain Scale in response to six daily prompts, and before and after exercise. Paired samples t-tests were conducted on changes in neuropathic pain and affect from pre to post-exercise. Bivariate Pearson's correlational analyses were computed between time of day, neuropathic pain and affect.

RESULTS

Participants experienced a significant decrease in neuropathic pain (t(5) = 3.93; p = 0.01) following completion of at least one bout of exercise. A large, but non-significant increase (Hgav = 0.76) in Feeling Scale scores occurred following one bout of exercise. Time of day, neuropathic pain and affect were significantly correlated for two participants.

CONCLUSIONS

Overall, results suggest exercise can reduce neuropathic pain, and may also increase feelings of pleasure. Given the inconsistent pattern of results across participants, further research is needed to look at both individual characteristics, and characteristics of exercise that may moderate changes in neuropathic pain and affect for adults with SCI.