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Kinnunen K, Robayo LE, Cherup NP, Frank SI, Widerström-Noga E. A preliminary study evaluating self-reported effects of cannabis and cannabinoids on neuropathic pain and pain medication use in people with spinal cord injury. FRONTIERS IN PAIN RESEARCH 2023; 4:1297223. [PMID: 38188193 PMCID: PMC10767995 DOI: 10.3389/fpain.2023.1297223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Approximately 60% of individuals with a spinal cord injury (SCI) experience neuropathic pain, which often persists despite the use of various pharmacological treatments. Increasingly, the potential analgesic effects of cannabis and cannabinoid products have been studied; however, little research has been conducted among those with SCI-related neuropathic pain. Therefore, the primary objective of the study was to investigate the perceived effects of cannabis and cannabinoid use on neuropathic pain among those who were currently or had previously used these approaches. Additionally, the study aimed to determine if common pain medications are being substituted by cannabis and cannabinoids. Participants (N = 342) were recruited from existing opt-in listserv sources within the United States. Of those, 227 met the inclusion criteria and were enrolled in the study. The participants took part in an anonymous online survey regarding past and current use of cannabis and their perceived effects on neuropathic pain, including the use of pain medication. Those in the sample reported average neuropathic pain intensity scores over the past week of 6.8 ± 2.1 (0 to 10 scale), reflecting a high moderate to severe level of pain. Additionally, 87.9% noted that cannabis reduced their neuropathic pain intensity by more than 30%, and 92.3% reported that cannabis helped them to better deal with their neuropathic pain symptoms. Most participants (83.3%) also reported substituting their pain medications with cannabis, with the most substituted medication categories being opioids (47.0%), gabapentinoids (42.8%) and over-the-counter pain medications (42.2%). These preliminary results suggest that cannabis and cannabinoids may be effective in reducing neuropathic pain among those with SCI and may help to limit the need for certain pain medications.
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Affiliation(s)
- Kristiina Kinnunen
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL, United States
| | - Linda E. Robayo
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL, United States
| | - Nicholas P. Cherup
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL, United States
| | - Scott I. Frank
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL, United States
- Neuroscience Graduate Program, University of Miami, Miami, FL, United States
| | - Eva Widerström-Noga
- The Miami Project to Cure Paralysis, University of Miami, Miami, FL, United States
- Neuroscience Graduate Program, University of Miami, Miami, FL, United States
- Department of Neurological Surgery, University of Miami, Miami, FL, United States
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Bombardier CH, Fann JR, Ehde DM, Reyes MR, Burns SP, Barber JK, Temkin NR. Collaborative Care Versus Usual Care to Improve Quality of Life, Pain, Depression, and Physical Activity in Outpatients With Spinal Cord Injury: The SCI-CARE Randomized Controlled Clinical Trial. J Neurotrauma 2023; 40:2667-2679. [PMID: 37597201 DOI: 10.1089/neu.2023.0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/21/2023] Open
Abstract
Our goal was to test the effectiveness of collaborative care (CC) versus usual care (UC) to improve treatment of pain, depression, physical inactivity, and quality of life in outpatients with spinal cord injury (SCI). We conducted a single blind parallel group randomized controlled trial. The setting was two outpatient SCI rehabilitation clinics within a large academic medical center. Participants were 174 outpatients who were on average 47.7 years old, 76% male, 76% white, 8% Hispanic, 47% tetraplegic, 95% more than 1 year post-SCI, and 45% on Medicare. The intervention consisted of a mental health-trained collaborative care manager (CM) integrated into two SCI rehabilitation medicine clinics and supervised by content experts in pain and mental health treatment. The CM provided assessment, medical care coordination, adherence support, outcome monitoring, and decision support along with brief psychological interventions to the patients via up to 12 in-person or telephone sessions. Among all participants, 61% chose to focus on pain; 31% on physical activity and 8% on depression. The primary outcome was quality of life as measured by the World Health Organization Quality of Life-BREF at the end of treatment (4 months). Secondary outcomes were quality of life at 8 months and pain intensity and interference, depression severity, and minutes per week of moderate to vigorous physical activity at 4 and 8 months. A total of 174 participants were randomized 1:1 to CC (n = 89) versus UC (n = 85). The primary analysis, a mixed-effects linear regression adjusting for time since injury and sex, revealed a non-significant trend for greater improvement in quality of life in CC versus UC at 4 months (p = 0.083). Secondary analyses showed that those receiving CC reported significantly greater improvement in pain interference at 4- and 8-months and in depression at 4-months, but no significant effect on physical activity. We conclude that in an outpatient SCI care setting, CC is a promising model for delivering integrated medical and psychological care and improving management of common, chronic, disabling conditions such and pain and depression.
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Affiliation(s)
- Charles H Bombardier
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Jesse R Fann
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Dawn M Ehde
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Maria R Reyes
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Stephen P Burns
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington, USA
| | - Jason K Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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Grasser P, Neto FR, Veloso JHCL, Gomes Costa RR, Dorneles JR. Mechanical diagnosis and therapy in musculoskeletal pain of individuals with spinal cord injury. J Spinal Cord Med 2023:1-9. [PMID: 37116180 DOI: 10.1080/10790268.2023.2197818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
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.
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Affiliation(s)
- Poliana Grasser
- Spinal Cord Injury Department, Sarah Network of Rehabilitation Hospital, Brasilia, Brazil
| | - Frederico Ribeiro Neto
- Spinal Cord Injury Department, Sarah Network of Rehabilitation Hospital, Brasilia, Brazil
| | - João H C L Veloso
- Spinal Cord Injury Department, Sarah Network of Rehabilitation Hospital, Rio de Janeiro, Brazil
| | - Rodrigo R Gomes Costa
- Spinal Cord Injury Department, Sarah Network of Rehabilitation Hospital, Brasilia, Brazil
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Felix ER, Cardenas DD, Bryce TN, Charlifue S, Lee TK, MacIntyre B, Mulroy S, Taylor H. Prevalence and impact of neuropathic and non-neuropathic pain in chronic spinal cord injury. Arch Phys Med Rehabil 2021; 103:729-737. [PMID: 34343523 DOI: 10.1016/j.apmr.2021.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 06/04/2021] [Accepted: 06/08/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Compare prevalence, intensity ratings, and interference ratings of neuropathic pain (NeuP) and nociceptive pain in people with chronic spinal cord injury (SCI) DESIGN: Cross-sectional survey SETTING: Six SCI Model System centers in the US PARTICIPANTS: Convenience sample of 391 individuals with traumatic SCI, aged 18 years or older, 81% male, 57% white INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: Survey based on the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) and the Spinal Cord Injury Pain Instrument (SCIPI), including 0-10 numerical ratings of pain intensity and pain interference with daily activities, mood, and sleep RESULTS: 80% of those surveyed reported having at least one pain problem; 58% reported two or more pain problems; 56% had probable NeuP; and 49% had non-NeuP. When comparing ratings for all pains (n=354 for NeuP, n=290 for non-NeuP) across subjects, probable NeuPs were significantly more intense (6.9 vs. 5.7) and interfered more with activities (5.2 vs. 3.7), mood (4.9 vs. 3.2), and sleep (5.4 vs. 3.6) than non-NeuPs (all p<0.001). However, when comparing ratings for probable NeuPs and non-NeuPs within subjects, for the subgroup of 94 participants with both pain types, only ratings for sleep interference were found to be significantly different between the pain types . Additionally, we found significantly greater prevalence of NeuP and non-NeuP for women compared to men, and of NeuP for those with paraplegia compared to those with tetraplegia. CONCLUSIONS Independent assessment of the pain conditions experienced by an individual with SCI is useful in understanding the differential impact that pain type has on quality of life. This is particularly important with regard to sleep interference and should be kept in mind when determining treatment strategies for meeting patient-centered outcome goals.
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Affiliation(s)
- Elizabeth R Felix
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL; Research Service, Miami Veterans Affairs Medical Center, Miami, FL.
| | - Diana D Cardenas
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL
| | - Thomas N Bryce
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Susan Charlifue
- SCI Research, Craig Hospital, Englewood, CO; Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, CO
| | - Tae Kyong Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | | | - Sara Mulroy
- Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, Downey, CA
| | - Heather Taylor
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, Houston, TX
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Varghese J, Anderson KD, Widerström-Noga E, Mehan U. A Primary Care Provider's Guide to Pain After Spinal Cord Injury: Screening and Management. Top Spinal Cord Inj Rehabil 2020; 26:133-143. [PMID: 33192039 PMCID: PMC7640913 DOI: 10.46292/sci2603-133] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Jithin Varghese
- Centre for Family Medicine-Family Health Team, Kitchener, Ontario, Canada
| | - Kim D. Anderson
- Department of Physical Medicine and Rehabilitation, Metrohealth Medical Center-Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Institute for Functional Restoration, Cleveland, Ohio, USA
- Cleveland Functional Electrical Stimulation Center, Cleveland, Ohio, USA
- North American SCI Consortium, Niagara Falls, New York, USA
| | - Eva Widerström-Noga
- Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
- Miami Project to Cure Paralysis, Miami, Florida, USA
| | - Upender Mehan
- Centre for Family Medicine-Family Health Team, Kitchener, Ontario, Canada
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Michailidou C, Marston L, De Souza LH. The experience of low back pain in people with incomplete spinal cord injury in the USA, UK and Greece. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2018. [DOI: 10.12968/ijtr.2018.25.7.316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Christina Michailidou
- Visiting research associate, Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK; Lecturer, University of Nicosia, Department of Life & Health Sciences, School of Sciences & Engineering, Nicosia, Cyprus
| | - Louise Marston
- Principal research associate, Department of Primary Care and Population Health, University College London, London, UK
| | - Lorraine H De Souza
- Pro Vice Chancellor (Equality, Diversity and Staff Development), Institute of Environment Health and Societies, Department of Clinical Sciences, College of Health and Life Sciences, Brunel University, London, UK
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Hatch MN, Cushing TR, Carlson GD, Chang EY. Neuropathic pain and SCI: Identification and treatment strategies in the 21st century. J Neurol Sci 2018; 384:75-83. [DOI: 10.1016/j.jns.2017.11.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 09/08/2017] [Accepted: 11/14/2017] [Indexed: 10/18/2022]
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Widerström-Noga E, Loeser JD, Jensen TS, Finnerup NB. AAPT Diagnostic Criteria for Central Neuropathic Pain. THE JOURNAL OF PAIN 2017; 18:1417-1426. [DOI: 10.1016/j.jpain.2017.06.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/30/2017] [Accepted: 06/15/2017] [Indexed: 01/21/2023]
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9
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Riediger C, Schuster T, Barlinn K, Maier S, Weitz J, Siepmann T. Adverse Effects of Antidepressants for Chronic Pain: A Systematic Review and Meta-analysis. Front Neurol 2017; 8:307. [PMID: 28769859 PMCID: PMC5510574 DOI: 10.3389/fneur.2017.00307] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 06/13/2017] [Indexed: 01/01/2023] Open
Abstract
Background Antidepressants are widely used in the treatment of chronic pain. Applied doses are lower than those needed to unfold an antidepressive effect. While efficacy of antidepressants for chronic pain has been reported in large randomized-controlled trials (RCT), there is inconsistent data on adverse effects and tolerability. We aimed at synthesizing data from RCT to explore adverse effect profiles and tolerability of antidepressants for treatment of chronic pain. Methods Systematic literature research and meta-analyses were performed regarding side effects and safety of different antidepressants in the treatment of chronic pain according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The National Center for Biotechnology Information library and MEDLINE were searched. Randomized placebo-controlled trials were included in quantitative data synthesis. Results Out of 1,975 screened articles, 33 papers published between 1995 and 2015 were included in our review and 23 studies were included in the meta-analyses. A higher risk for adverse effects compared to placebo was observed in all antidepressants included in our analyses, except nortriptyline. The most prevalent adverse effects were dry mouth, dizziness, nausea, headache, and constipation. Amitriptyline, mirtazapine, desipramine, venlafaxine, fluoxetine, and nortriptyline showed the highest placebo effect-adjusted risk of adverse effects. Risk for withdrawal due to adverse effects was highest in desipramine (risk ratio: 4.09, 95%-confidence interval [1.31; 12.82]) followed by milnacipran, venlafaxine, and duloxetine. The most common adverse effects under treatment with antidepressants were dry mouth, dizziness, nausea, headache, and constipation followed by palpitations, sweating, and drowsiness. However, overall tolerability was high. Each antidepressant showed distinct risk profiles of adverse effects. Conclusion Our synthesized data analysis confirmed overall tolerability of low-dose antidepressants for the treatment of chronic pain and revealed drug specific risk profiles. This encompassing characterization of adverse effect profiles might be useful in defining multimodal treatment regimens for chronic pain which also consider patients’ comorbidities and co-medication.
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Affiliation(s)
- Carina Riediger
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden, Germany
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Sarah Maier
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden, Germany.,Department of Pedriatric Oncology, University Hospital Eppendorf, Universität Hamburg, Hamburg, Germany
| | - Jürgen Weitz
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden, Germany.,Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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Hitzig SL, Hunter JP, Ballantyne EC, Katz J, Rapson L, Craven BC, Boschen KA. Outcomes and reflections on a consensus-building workshop for developing a spinal cord injury-related chronic pain research agenda. J Spinal Cord Med 2017; 40:258-267. [PMID: 26828394 PMCID: PMC5472012 DOI: 10.1080/10790268.2015.1136115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
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.
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Affiliation(s)
- Sander L. Hitzig
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
- Institute for Life Course and Aging, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Judith P. Hunter
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Elena C. Ballantyne
- St- Joseph's Healthcare, Hamilton, Ontario, Canada
- Bieman-Copland & Associates, St. Catharines, Ontario, Canada
| | - Joel Katz
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
- Department of Psychology, Faculty of Health, York University, Toronto, Ontario, Canada
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Linda Rapson
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - B. Catharine Craven
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kathryn A. Boschen
- Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Ontario, Canada
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11
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Ullrich PM. "People Who Have Something Better To Do Don't Suffer As Much". J Spinal Cord Med 2017; 40:255-257. [PMID: 28402229 PMCID: PMC5472011 DOI: 10.1080/10790268.2017.1314881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Philip M. Ullrich
- Correspondence to: Philip M. Ullrich, PhD, Behavioral Health Services, Kaiser Permanente Washington, Seattle, WA, USA.
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12
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Chan CWL, Miller WC, Querée M, Noonan VK, Wolfe DL. The development of an outcome measures toolkit for spinal cord injury rehabilitation. The Canadian Journal of Occupational Therapy 2017; 84:119-129. [PMID: 28378605 DOI: 10.1177/0008417417690170] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) is a complex medical condition that can be difficult to monitor. PURPOSE This study aimed to establish a common set of validated outcome measures specifically for SCI clinical practice. METHOD In a three-round online Delphi process, experts in SCI care across Canada suggested and ranked outcome measures for clinical practice. The facilitators provided feedback between rounds and determined if consensus (at least 75% agreement) was reached on a single outcome measure per clinical area. FINDINGS One hundred and forty-eight outcome measures were initially considered for inclusion. After three rounds, consensus was reached for 23 out of 30 clinical areas. In the remaining seven, more than one outcome measure was recommended. The final toolkit comprises 33 outcome measures with sufficient measurement properties for use with a SCI population. IMPLICATIONS An outcome measures toolkit validated specifically for SCI should lead to improved identification of best practice and enable clinicians to monitor client progress effectively.
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13
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Ajo R, Segura A, Mira L, Inda MDM, Alfayate R, Sánchez-Barbie A, Margarit C, Peiró AM. The relationship of salivary testosterone and male sexual dysfunction in opioid-associated androgen deficiency (OPIAD). Aging Male 2017; 20:1-8. [PMID: 27750480 DOI: 10.1080/13685538.2016.1185408] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Opioids are an effective treatment for chronic non-malignant pain (CNP). Long-term use risks and side effects such as opioid-induced androgen deficiency (OPIAD) exist. This could be measured by saliva testosterone (Sal-T). OBJECTIVES To evaluate OPIAD in long-term opioid use in CNP patients. METHODS A cross-sectional study included CNP male outpatients under opioid treatment. Total-Testosterone (Total-T), Free-Testosterone (Free-T), Bio-Testosterone (Bio-T) and Sal-T were measured. Correlations were calculated by Spearman's rho (SPSS 20). RESULTS From 2012 to 2014, 134 from 249 (54%) consecutive male outpatients reported erectile dysfunction (ED), 37% of them related to opioids and 19% evidenced OPIAD. A total of 120 subjects (94 cases and 26 matched-controls) were included. A significantly lower luteinizing hormone, Total-T and Free-T were found, as well as, a significant correlation between Sal-T and Total-T (r = 0.234, p = 0.039), Bio-T (r = 0.241, p = 0.039), IIEF (r = 0.363, p = 0.003) and HAD-anxiety (r = -0.414, p = 0.012) in OPIAD patients. Sal-T levels were significantly lower in patients with severe-moderate ED versus mild ED (p = 0.045) and in patients with severe ED versus moderate-mild ED (p = 0.036). CONCLUSIONS These data demonstrate the high prevalence of ED in long-term use of opioids, part of this is associated to OPIAD, which can be tested by Sal-T as a non-invasive approach.
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Affiliation(s)
- Raquel Ajo
- a Research Unit, Foundation for the Promotion of Health Research and Biomedicine of Valencia (FISABIO) , Alicante , Spain
| | - Ana Segura
- b Andrology Unit, University General Hospital of Alicante (HGUA) , Alicante , Spain
| | - Laura Mira
- c Occupational Observatory, University Miguel Hernández of Elche (UMH) , Alicante , Spain
| | - María-Del-Mar Inda
- a Research Unit, Foundation for the Promotion of Health Research and Biomedicine of Valencia (FISABIO) , Alicante , Spain
| | | | | | | | - Ana M Peiró
- a Research Unit, Foundation for the Promotion of Health Research and Biomedicine of Valencia (FISABIO) , Alicante , Spain
- g Clinical Pharmacology, HGUA , Alicante , Spain
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Shank CD, Walters BC, Hadley MN. Management of acute traumatic spinal cord injuries. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:275-298. [PMID: 28187803 DOI: 10.1016/b978-0-444-63600-3.00015-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute traumatic spinal cord injury (SCI) is a devastating disease process affecting tens of thousands of people across the USA each year. Despite the increase in primary prevention measures, such as educational programs, motor vehicle speed limits, automobile running lights, and safety technology that includes automobile passive restraint systems and airbags, SCIs continue to carry substantial permanent morbidity and mortality. Medical measures implemented following the initial injury are designed to limit secondary insult to the spinal cord and to stabilize the spinal column in an attempt to decrease devastating sequelae. This chapter is an overview of the contemporary management of an acute traumatic SCI patient from the time of injury through the stay in the intensive care unit. We discuss initial triage, immobilization, and transportation of the patient by emergency medical services personnel to a definitive treatment facility. Upon arrival at the emergency department, we review initial trauma protocols and the evidence-based recommendations for radiographic evaluation of the patient's vertebral column. Finally, we outline closed cervical spine reduction and various aggressive medical therapies aimed at improving neurologic outcome.
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Affiliation(s)
- C D Shank
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - B C Walters
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - M N Hadley
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA.
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15
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Association of pain, social support and socioeconomic indicators in patients with spinal cord injury in Iran. Spinal Cord 2016; 55:180-186. [DOI: 10.1038/sc.2016.160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 01/08/2023]
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Approaches to Demonstrating the Reliability and Validity of Core Diagnostic Criteria for Chronic Pain. THE JOURNAL OF PAIN 2016; 17:T118-31. [DOI: 10.1016/j.jpain.2015.10.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/24/2015] [Accepted: 10/12/2015] [Indexed: 01/03/2023]
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The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: screening and diagnosis recommendations. Spinal Cord 2016; 54 Suppl 1:S7-S13. [DOI: 10.1038/sc.2016.89] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Watson JC, Sandroni P. Central Neuropathic Pain Syndromes. Mayo Clin Proc 2016; 91:372-85. [PMID: 26944242 DOI: 10.1016/j.mayocp.2016.01.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/24/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- James C Watson
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN.
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Analysis of the behavioral, cellular and molecular characteristics of pain in severe rodent spinal cord injury. Exp Neurol 2016; 278:91-104. [PMID: 26808661 DOI: 10.1016/j.expneurol.2016.01.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 01/07/2016] [Accepted: 01/12/2016] [Indexed: 12/31/2022]
Abstract
Human SCI is frequently associated with chronic pain that is severe and refractory to medical therapy. Most rodent models used to assess pain outcomes in SCI apply moderate injuries to lower thoracic spinal levels, whereas the majority of human lesions are severe in degree and occur at cervical or upper thoracic levels. To better model and understand mechanisms associated with chronic pain after SCI, we subjected adult rats to T3 severe compression or complete transection lesions, and examined pain-related behaviors for three months. Within one week after injury, rats developed consistent forepaw pain-related behaviors including increased spontaneous lifts, tactile allodynia and cold sensitivity that persisted for three months. Place escape avoidance testing confirmed that withdrawal of the forepaws from a von Frey stimulus represented active pain-related aversion. Spontaneous and evoked pain-related measures were attenuated by gabapentin, further indicating that these behaviors reflect development of pain. Spinal level of injury was relevant: rats with T11 severe SCI did not exhibit forepaw pain-related behaviors. Immunoblotting and immunofluorescence of C6-C8 spinal dorsal horn, reflecting sensory innervation of the forepaw, revealed: 1) expansion of CGRP immunoreactivity in lamina I/II; 2) increased GAP-43 expression; and 3) increased IBA1, GFAP and connexin-43 expression. These findings indicate that aberrant pain fiber sprouting and gliopathy occur after severe SCI. Notably, satellite glial cells (SGCs) in C6-C8 DRGs exhibited increases in GFAP and connexin-43, suggesting ongoing peripheral sensitization. Carbenoxolone, a gap junction inhibitor, and specific peptide inhibitors of connexin-43, ameliorated established tactile allodynia after severe SCI. Collectively, severe T3 SCI successfully models persistent pain states and could constitute a useful model system for examining candidate translational pain therapies after SCI.
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Abstract
OBJECTIVES Pain catastrophizing is thought to play a causal role in the development and maintenance of chronic pain and its negative impact on functioning. However, few studies have examined the factors that might contribute to the development and maintenance of catastrophizing. The Anterior Asymmetry and Emotion (AAE) model hypothesizes that more activity in left anterior brain regions is associated with a tendency to engage in approach responses (often, but not always, associated with positive valance), and that more right anterior activity is associated with a tendency to engage in more withdrawal responses (often associated with negative valance). Given the consistent associations found between catastrophizing and both (1) approach versus avoidance pain coping style; and (2) affective responses to pain, the AAE model would predict that more left (vs. right) anterior brain activity would prospectively predict future catastrophizing. METHODS Anterior asymmetry measures computed using electroencephalogram data from 30 individuals with spinal cord injury were correlated with catastrophizing scores obtained 2 years after the electroencephalograph recording. RESULTS Consistent with the AAE model, anterior asymmetry scores reflecting greater left than right anterior activity were negatively associated with subsequent catastrophizing. CONCLUSIONS The study findings identify a biological factor that may be associated with greater vulnerability to pain-related catastrophizing. If replicated in future research, the findings suggest new possibilities for treating catastrophizing, which may then contribute to improved pain treatment outcomes.
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Affiliation(s)
- Mark P. Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Ann Gianas
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Leslie H. Sherlin
- Department of Psychology, Northern Arizona University, Flagstaff, Arizona, USA, and Nova Tech EEG, Mesa, Arizona, USA
| | - Jon D. Howe
- Department of Psychology, University of Washington, Seattle, Washington, USA
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Jensen MP, Tomé-Pires C, Solé E, Racine M, Castarlenas E, de la Vega R, Miró J. Assessment of pain intensity in clinical trials: individual ratings vs composite scores. PAIN MEDICINE 2014; 16:141-8. [PMID: 25280226 DOI: 10.1111/pme.12588] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the reliability of findings suggesting that composite scores made up of just two ratings of recalled pain may be adequately reliable and valid for assessing outcome in pain clinical trials. DESIGN Secondary analyses of data from a study where the responsivity of the outcome measures was a critical concern; that is, a study with few subjects testing the effects of a treatment that had only modest effects. Ten adults with spinal cord injury rated four domains of pain intensity (current pain and 24-hour recalled worst, least, and average pain) on four occasions before and after 12 sessions of neurofeedback treatment. We evaluated the reliability and validity of four single ratings and 16 different composite scores. RESULTS None of the single-item scales performed adequately. However, composite scores made up of two items or more yielded consistent effect size estimates. CONCLUSIONS The findings provide additional evidence that two-item composite scores may be adequate for assessing the primary outcome of pain intensity in chronic pain clinical trials. Additional research is needed to further establish the generalizability of these findings.
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Affiliation(s)
- Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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Dijkers MP, Bryce TN. Introducing the International Spinal Cord Injury Pain (ISCIP) Classification. Pain Manag 2014; 2:311-4. [PMID: 24654713 DOI: 10.2217/pmt.12.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Marcel P Dijkers
- Mount Sinai School of Medicine, Department of Rehabilitation Medicine, Box 1240, One Gustave Levy Place, New York, NY 10029-6574, USA
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Abstract
SUMMARY An important and detrimental effect of spinal cord injury (SCI) is pain, which develops in approximately two-thirds of all SCI patients, while approximately half of SCI patients develop chronic neuropathic pain (NP). Thus far, there is no cure for SCI NP, and oral pharmacological intervention is often inadequate, commonly resulting in a pain reduction of only 20-30%. In this short review, we will present an overview of the important features of SCI pain including taxonomy, epidemiology and classification, as well as a suggested oral pharmacological treatment strategy for SCI NP and the current evidence available from randomized placebo-controlled trials. Considerations and evidence for the nonpharmacological treatment of SCI will be discussed briefly.
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Affiliation(s)
- Cathrine Baastrup
- Danish Pain Research Center, Aarhus University Hospital, Noerrebrogade 44, Building 1A, DK-8000 Aarhus C, Denmark
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Bryce TN, Richards JS, Bombardier CH, Dijkers MP, Fann JR, Brooks L, Chiodo A, Tate DG, Forchheimer M. Screening for neuropathic pain after spinal cord injury with the Spinal Cord Injury Pain Instrument (SCIPI): a preliminary validation study. Spinal Cord 2014; 52:407-12. [DOI: 10.1038/sc.2014.21] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/10/2014] [Accepted: 01/25/2014] [Indexed: 11/09/2022]
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Widerström-Noga E, Biering-Sørensen F, Bryce TN, Cardenas DD, Finnerup NB, Jensen MP, Richards JS, Siddall PJ. The International Spinal Cord Injury Pain Basic Data Set (version 2.0). Spinal Cord 2014; 52:282-6. [DOI: 10.1038/sc.2014.4] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/11/2013] [Accepted: 01/03/2014] [Indexed: 11/09/2022]
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Jensen MP, Gertz KJ, Kupper AE, Braden AL, Howe JD, Hakimian S, Sherlin LH. Steps toward developing an EEG biofeedback treatment for chronic pain. Appl Psychophysiol Biofeedback 2013; 38:101-8. [PMID: 23532434 DOI: 10.1007/s10484-013-9214-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic pain, usually refractory to analgesics, is a significant problem for many individuals with spinal cord injury (SCI). Preliminary studies suggest that electroencephalography (EEG) biofeedback (also known as neurofeedback, NF) has the potential to help patients with otherwise refractory chronic pain. However, there remain many unanswered questions about the effects and mechanisms of this treatment. We studied 13 individuals with SCI and chronic pain with NF. Ten of the 13 individuals completed 4 sessions each of three different neurofeedback protocols assigned in random order for a total of 12 NF sessions. All three protocols had similar immediate effects on pain intensity. In addition, the participants reported modest pre- to post-treatment decreases in worst pain and pain unpleasantness following completion of the 12 NF sessions. These improvements were maintained at 3-month follow-up. The majority of the participants felt they benefited from and were satisfied with the treatment. No significant effects on measures of other outcome domains (sleep quality, pain interference and fatigue) were observed, although there was a non-significant trend for an increase in fatigue. Finally, pre- to post-treatment changes in EEG bandwidth activity, consistent with the training protocols, were observed in θ and α but not β frequencies. The findings provide preliminary support for the potential efficacy of NF for the treatment of SCI-related pain, and suggest that further clinical studies are warranted.
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Affiliation(s)
- Mark P Jensen
- Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington, Box 359612, 325 Ninth Avenue, Seattle, WA 98104, USA.
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Jensen MP, Sherlin LH, Askew RL, Fregni F, Witkop G, Gianas A, Howe JD, Hakimian S. Effects of non-pharmacological pain treatments on brain states. Clin Neurophysiol 2013; 124:2016-24. [PMID: 23706958 PMCID: PMC3759647 DOI: 10.1016/j.clinph.2013.04.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 03/31/2013] [Accepted: 04/13/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To (1) evaluate the effects of a single session of four non-pharmacological pain interventions, relative to a sham tDCS procedure, on pain and electroencephalogram- (EEG-) assessed brain oscillations, and (2) determine the extent to which procedure-related changes in pain intensity are associated with changes in brain oscillations. METHODS 30 individuals with spinal cord injury and chronic pain were given an EEG and administered measures of pain before and after five procedures (hypnosis, meditation, transcranial direct current stimulation [tDCS], neurofeedback, and a control sham tDCS procedure). RESULTS Each procedure was associated with a different pattern of changes in brain activity, and all active procedures were significantly different from the control procedure in at least three bandwidths. Very weak and mostly non-significant associations were found between changes in EEG-assessed brain activity and pain. CONCLUSIONS Different non-pharmacological pain treatments have distinctive effects on brain oscillation patterns. However, changes in EEG-assessed brain oscillations are not significantly associated with changes in pain, and therefore such changes do not appear useful for explaining the benefits of these treatments. SIGNIFICANCE The results provide new findings regarding the unique effects of four non-pharmacological treatments on pain and brain activity.
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Affiliation(s)
- Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
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A pilot feasibility study of massage to reduce pain in people with spinal cord injury during acute rehabilitation. Spinal Cord 2013; 51:847-51. [PMID: 24042991 PMCID: PMC3815956 DOI: 10.1038/sc.2013.104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/26/2013] [Accepted: 06/27/2013] [Indexed: 11/29/2022]
Abstract
Objective To determine the feasibility of conducting a randomized controlled trial of massage therapy for patients with new spinal cord injury (SCI) during acute inpatient rehabilitation. Design A pilot single-center, randomized, single-blind, cross-over clinical trial. Setting Free-standing, not-for-profit, comprehensive rehabilitation center specializing in SCI rehabilitation Participants Forty adults ages 18 years and older undergoing acute rehabilitation following spinal cord injury reporting any type of pain. Intervention Rehabilitation nurses trained to give broad compression massage (BCM) and a control light contact touch (LCT) treatments. Participants were randomized to receive either BCM or LCT first, in six 20 minute treatment sessions over two weeks, with a one week wash-out between the two-week treatment periods. Main Outcome Measures Primary outcomes were changes in pain intensity and in fatigue, measured daily. Secondary outcomes included depressive symptoms measured by the Patient Health Questionnaire-9 (PHQ-9) and an assessment of pain medication usage. Results Pain intensity was higher at baseline and reduced more in the LCT-first group compared to the BCM-first group in period 1 (p=0.014); although this pattern was not found in period 2 (p=0.58). LCT and BCM groups did not significantly differ on any secondary measures except PHQ-9. Conclusions This study demonstrates the feasibility of using rehabilitation nurses to provide tactile therapy to patients with SCI and suggests a model for controlled clinical trials examining the efficacy of massage therapies. While efficacy was difficult to assess, broad compression massage was safe and well tolerated.
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Michailidou C, Marston L, De Souza LH, Sutherland I. A systematic review of the prevalence of musculoskeletal pain, back and low back pain in people with spinal cord injury. Disabil Rehabil 2013; 36:705-15. [DOI: 10.3109/09638288.2013.808708] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Theodore N. Clinical Assessment Following Acute Cervical Spinal Cord Injury. Neurosurgery 2013; 72 Suppl 2:40-53. [DOI: 10.1227/neu.0b013e318276edda] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Beverly C. Walters
- Division of Neurological Surgery
- Department of Neurosciences, Inova Health System, Falls Church, Virginia
| | | | - Sanjay S. Dhall
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Daniel E. Gelb
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - R. John Hurlbert
- Department of Clinical Neurosciences, University of Calgary Spine Program, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Curtis J. Rozzelle
- Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy C. Ryken
- Iowa Spine & Brain Institute, University of Iowa, Waterloo/Iowa City, Iowa
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Lee S, Zhao X, Hatch M, Chun S, Chang E. Central Neuropathic Pain in Spinal Cord Injury. ACTA ACUST UNITED AC 2013; 25:159-172. [PMID: 25750485 DOI: 10.1615/critrevphysrehabilmed.2013007944] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Spinal cord injury (SCI) is a devastating medical condition affecting 1.2 million people in the United States. Central neuropathic pain is one of the most common medical complications of SCI. Current treatment options include opioids, antiepileptic agents such as gabapentin, antispastic agents such as baclofen or tizanidine, and tricyclic acid. Other options include complementary, nonpharmacological treatment such as exercise or acupuncture, interventional treatments, and psychological approaches. Although these treatment options exist, central neuropathic pain in patients with SCI is still extremely difficult to treat because of its complexity. To develop and provide more effective treatment options to these patients, proper assessment of and classification tools for central neuropathic pain, as well as a better understanding of the pathophysiology, are needed. A combination of approaches, from standard general pain assessments to medically specific questions unique to SCI pathophysiology, is essential for this population. A multidisciplinary approach to patient care, in addition with a better understanding of pathophysiology and diagnosis, will lead to improved management and treatment of patients with SCI displaying central neuropathic pain. Here we summarize the most recent classification tools, pathophysiology, and current treatment options for patients with SCI with central neuropathic pain.
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Affiliation(s)
- Sujin Lee
- Department of Physical Medicine and Rehabilitation, University of California, Irvine, CA
| | - Xing Zhao
- Department of Physical Medicine and Rehabilitation, University of California, Irvine, CA
| | - Maya Hatch
- Reeve-Irvine Research Center, University of California, Irvine, CA
| | - Sophia Chun
- Spinal Cord Injury Medicine/Disease, Long Beach VA Hospital, Long Beach, CA
| | - Eric Chang
- Department of Physical Medicine and Rehabilitation, University of California, Irvine, CA
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International Spinal Cord Injury Pain (ISCIP) Classification: Part 2. Initial validation using vignettes. Spinal Cord 2012; 50:404-12. [DOI: 10.1038/sc.2012.2] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Ditunno JF, Cardenas DD, Formal C, Dalal K. Advances in the rehabilitation management of acute spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:181-95. [PMID: 23098713 DOI: 10.1016/b978-0-444-52137-8.00011-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aggressive assessment and management of the secondary complications in the hours and days following spinal cord injury (SCI) leads to restoration of function in patients through intervention by a team of rehabilitation professionals. The recent certification of SCI physicians, newly validated assessments of impairment and function measures, and international databases agreed upon by SCI experts should lead to documentation of improved rehabilitation care. This chapter highlights recent advances in assessment and treatment based on evidence-based classification of literature reviews and expert opinion in the acute phase of SCI. A number of these reviews are the product of the Consortium for Spinal Cord Medicine, which offers clinical practice guidelines for healthcare professionals. Recognition of and early intervention for problems such as bradycardia, orthostatic hypotension, deep vein thrombosis/pulmonary embolism, and early ventilatory failure will be addressed although other chapters may discuss some issues in greater detail. Early assessment and intervention for neurogenic bladder and bowel function has proven effective in the prevention of renal failure and uncontrolled incontinence. Attention to overuse and disuse with training and advanced technology such as functional electrical stimulation have reduced pain and disability associated with upper extremity deterioration and improved physical fitness. Topics such as chronic pain, spasticity, sexual dysfunction, and pressure sores will be covered in more detail in additional chapters. However, the comprehensive and integrated rehabilitation by specialized SCI teams of physicians, nurses, therapists, social workers, and psychologists immediately following SCI has become the standard of care throughout the world.
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Affiliation(s)
- John F Ditunno
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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Bryce TN, Biering-Sørensen F, Finnerup NB, Cardenas DD, Defrin R, Lundeberg T, Norrbrink C, Richards JS, Siddall P, Stripling T, Treede RD, Waxman SG, Widerström-Noga E, Yezierski RP, Dijkers M. International Spinal Cord Injury Pain Classification: part I. Background and description. Spinal Cord 2011; 50:413-7. [DOI: 10.1038/sc.2011.156] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Furlan JC, Noonan V, Singh A, Fehlings MG. Assessment of impairment in patients with acute traumatic spinal cord injury: a systematic review of the literature. J Neurotrauma 2011; 28:1445-77. [PMID: 20030559 PMCID: PMC3143408 DOI: 10.1089/neu.2009.1152] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The most common primary end-point of the trial on treatment of traumatic spinal cord injury (SCI) is the degree of impairment. The American Spinal Injury Association (ASIA) Standards have been widely used to assess motor function and pin-prick and light-touch sensory function. In addition, pain assessment is another clinically relevant aspect of the impairment in individuals with SCI. Given this, we sought to systematically review the studies that focused on the psychometric properties of ASIA Standards and all previously used outcome measures of pain in the SCI population in the acute care setting. For the primary literature search strategy, the MEDLINE, CINAHL, EMBASE, and Cochrane databases were sought out. Subsequently, a secondary search strategy was carried out using the articles listed in the references of meta-analysis, systematic, and non-systematic review articles. Two reviewers (JCF and VN) independently selected the articles that fulfill the inclusion and exclusion, assessed the level of evidence of each article, and appraised the psychometric properties of each instrument. Divergences during those steps were solved by consensus between both reviewers. Of 400 abstracts captured in our primary search strategy on the ASIA Standards, 16 full articles fulfilled the inclusion and exclusion criteria. An additional 40 references were obtained from two prior systematic reviews on ASIA Standards. While 45 of 56 of the studies on ASIA Standards provided level 4 evidence, there were 11 level 2b evidence studies. Convergent construct validity (n = 34), reliability (n = 12), and responsiveness (n = 10) were the most commonly studied psychometric properties of the ASIA Standards, but two prior studies examined their content validity. Of the 267 abstracts yielded in our primary search on pain assessment, 24 articles with level 4 evidence fulfilled the inclusion and exclusion criteria. There was no study that examined pain assessment in the acute care setting. While 18 of 24 articles studied an instrument for assessment of pain intensity, the remaining six studies were focused on classifications of pain in the SCI population. In conclusion, the ASIA Standards represent an appropriate instrument to categorize and evaluate spinal cord injured adults over time with respect to their motor and sensory function. Nevertheless, further investigation of the psychometric properties of the ASIA Standards is recommended due to a lack of studies focused on some key elements of responsiveness, including minimal clinically important difference. The visual analog scale (VAS) is the most commonly studied instrument of assessment of pain intensity in the SCI population. However, further investigation is required with regard to its reliability and responsiveness in the SCI population. Our results also suggest that there is no instrument with appropriate psychometric properties for this particular population.
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Affiliation(s)
- Julio C. Furlan
- Department of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Vanessa Noonan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Anoushka Singh
- Department of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Department of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
- Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Division of Neurosurgery and Spinal Program University of Toronto, Toronto, Ontario, Canada
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Modirian E, Pirouzi P, Soroush M, Karbalaei-Esmaeili S, Shojaei H, Zamani H. Chronic Pain after Spinal Cord Injury: Results of a Long-Term Study. PAIN MEDICINE 2010; 11:1037-43. [DOI: 10.1111/j.1526-4637.2010.00865.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Cardenas DD, Felix ER. Pain after Spinal Cord Injury: A Review of Classification, Treatment Approaches, and Treatment Assessment. PM R 2009; 1:1077-90. [DOI: 10.1016/j.pmrj.2009.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 06/29/2009] [Accepted: 07/07/2009] [Indexed: 10/20/2022]
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Jensen MP, Barber J, Romano JM, Hanley MA, Raichle KA, Molton IR, Engel JM, Osborne TL, Stoelb BL, Cardenas DD, Patterson DR. Effects of self-hypnosis training and EMG biofeedback relaxation training on chronic pain in persons with spinal-cord injury. Int J Clin Exp Hypn 2009; 57:239-68. [PMID: 19459087 PMCID: PMC2730649 DOI: 10.1080/00207140902881007] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Thirty-seven adults with spinal-cord injury and chronic pain were randomly assigned to receive 10 sessions of self-hypnosis (HYP) or EMG biofeedback relaxation (BIO) training for pain management. Participants in both treatment conditions reported substantial, but similar, decreases in pain intensity from before to after the treatment sessions. However, participants in the HYP condition, but not the BIO condition, reported statistically significant decreases in daily average pain pre- to posttreatment. These pre- to posttreatment decreases in pain reported by the HYP participants were maintained at 3-month follow-up. Participants in the HYP condition, but not the BIO condition, also reported significant pre- to posttreatment increases in perceived control over pain, but this change was not maintained at the 3-month follow-up.
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Affiliation(s)
- Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington 98195-6490, USA
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Neuropathic pain in spinal cord injury: identification, classification, evaluation. Ann Phys Rehabil Med 2009; 52:83-102. [PMID: 19909700 DOI: 10.1016/j.rehab.2008.12.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 12/17/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Chronic pain is very frequent after spinal cord injury, recent data showing that at least 80% of the patients experience pain, one-third at a severe level. The main objective of the present work is to report and discuss data regarding tools and procedures for the screening, diagnosis, and evaluation of neuropathic pain in spinal cord injury patients. MATERIAL AND METHOD The method used is that developed by the SOFMER, which associated a systematic review of the literature and a selection of published works by a scientific commitee, an analysis of data performed by a binom neuropathic pain/physical medicine and rehabilitation (PM&R) specialists, an evaluation of current practices during an expert consensus conference and via Internet, and finally a validation of the whole work by a pluridisciplinary expert panel. RESULTS The literature provides an important series of studies on pain in spinal injury, but without specific data about neuropathic pain in this population. Some specific diagnostic and evaluation tools for neuropathic pain have been developed these last years, while numerous classifications, based on various criteria, have been proposed, some of them exhibiting some advantages for a pragmatic application and being in parallel in accordance with recent nosological and physiopathological advances. DISCUSSION The DN4 questionnaire can be used for the screening and identification of neuropathic pain in this population of patients, often suffering from various types of pain. The use of the Spinal Cord Injury Pain Task Force of the International Association of the Study of Pain classification (SCIP-IASP), although some limitations, is recommended since taking into account physiopathology, localisation, and nature of pain. Daily uses of Visual Analogic Scale (VAS) or Numeric Scale (NS) are an obvious need and that of the questionnaire Douleur de Saint-Antoine (QDSA) for global evaluation and more specifically of the Neuropathic Pain Symptom Inventory (NPSI) for neuropathic pain are highly recommended.
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Ullrich PM, Jensen MP, Loeser JD, Cardenas DD. Pain intensity, pain interference and characteristics of spinal cord injury. Spinal Cord 2008; 46:451-5. [PMID: 18283293 DOI: 10.1038/sc.2008.5] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Postal survey. OBJECTIVES To examine if the intensity of pain in persons with spinal cord injury (SCI) varied as a function of pain site, and to identify the patient and SCI characteristics associated with pain location, pain intensity and pain interference in a sample of persons with SCI. SETTING Community sample, United States. METHODS A postal survey including measures of pain intensity, pain interference, other pain, demographic and medical characteristics was completed by 238 adults with SCI. RESULTS Average pain intensity was moderate and pain was common across the body. Demographic and medical variables, including SCI level, were generally not associated with pain prevalence, intensity and interference. However, persons with higher level injuries were more likely to report upper extremity pain than persons with paraplegic injuries. The lower body was the location of the highest pain ratings. CONCLUSION Persons with SCI tend to experience high pain intensity over multiple body locations. Lower body pain was as common as upper extremity pain, but tended to be more intense.
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Affiliation(s)
- P M Ullrich
- Department of Veterans Affairs (VA), Spinal Cord Injury Quality Enhancement Research Initiative, VA Puget Sound Healthcare System, Seattle, WA, USA.
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Richards S, Kezar L, Ness T. Ethics in Pain Management of Persons with Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2008. [DOI: 10.1310/sci1303-95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Rintala DH, Holmes SA, Courtade D, Fiess RN, Tastard LV, Loubser PG. Comparison of the Effectiveness of Amitriptyline and Gabapentin on Chronic Neuropathic Pain in Persons With Spinal Cord Injury. Arch Phys Med Rehabil 2007; 88:1547-60. [DOI: 10.1016/j.apmr.2007.07.038] [Citation(s) in RCA: 155] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Revised: 07/05/2007] [Accepted: 07/09/2007] [Indexed: 11/15/2022]
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Jensen M, Stoelb B, Molton I. Measuring Pain in Persons with Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2007. [DOI: 10.1310/sci1302-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Widerström-Noga E, Cardenas D. The Role of Brain Imaging in SCI-Related Pain. Top Spinal Cord Inj Rehabil 2007. [DOI: 10.1310/sci1302-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Felix E, Cardena D. Future Directions for Evidence-Based Pain Management. Top Spinal Cord Inj Rehabil 2007. [DOI: 10.1310/sci1302-94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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