“But I know what works” – patients’ experience of spinal cord injury neuropathic pain management

Healthcare providers perspective of chronic pain management in persons with traumatic spinal cord injury accessing the public system in a region of South Africa

PURPOSE

Persons with traumatic spinal cord injury (PWTSCI) have expressed a lack of education from healthcare providers and poor shared-decision making between providers and clients. The aim was to explore the healthcare providers' perspective on factors influencing the optimal management of chronic pain.

METHODS

Healthcare providers were recruited from two institutions at tertiary healthcare level. Interviews explored current chronic pain management practices, influencing factors and recommendations for improvement. Data saturation occurred after interviewing 11 participants. Thematic analysis was used through a socio-ecological model.

RESULTS

The challenges to optimal pain management include appropriate assessment and management of psychological health (intrapersonal level), substance abuse amongst patients (intrapersonal level), access to medication for providers and lack of knowledge by providers (interpersonal and organizational level). To improve chronic pain management, an interdisciplinary team approach should be operationalized at policy and organizational level, monitoring and adjustment of interventions should take place (interpersonal), and family members/caregivers should be involved in the planning and monitoring (interpersonal).

CONCLUSION

Factors, at the interpersonal, intrapersonal, organizational and policy levels, influence optimal chronic pain management in the traumatic spinal cord injury (TSCI) population. To mitigate challenges, guidelines for chronic pain management should be developed, particularly for low-resourced developing countries.

"I don't know the correct way to describe it": neuropathic pain experiences among athletes with spinal cord injury

Background

Chronic pain among athletes is often misinterpreted as tissue damage resulting from sport. While researchers have started to examine neuropathic pain among athletes with spinal cord injury (SCI), there is a need to develop a deeper understanding of their neuropathic pain symptoms and experiences, to support the development of evidence-based pain management protocols.

Objectives

The primary purpose of this study was to describe neuropathic pain experienced by athletes with SCI. A secondary purpose was to compare athletes' neuropathic pain symptoms when measured by two different clinical pain assessment tools and describe their experiences when trying to communicate their neuropathic pain.

Methods

47 athletes with SCI completed the International Spinal Cord Injury Pain Basic Data Set (V.2.0), Douleur Neuropathique 4 (DN4), and two open-ended pain questions over the telephone.

Results

66% of participants reported experiencing moderate-intensity neuropathic pain (Mpain intensity=5.32±1.78) and mild-to-moderate pain interference with activities of daily living (Mpain interference=3.55±2.11) and sleep (Mpain interference4.68±2.92). Overall, participants reported significantly more neuropathic pain symptoms in response to DN4 questions (M=4.62±1.38) versus open-ended pain questions (M=2.13±1.08), p<0.001. Participants reported difficulty with identifying neuropathic pain, describing their pain symptoms and identifying pain locations.

Conclusion

Athletes with SCI reported moderate-intensity neuropathic pain. However, they struggled with communicating their neuropathic pain without being prompted with a list of symptoms. To guide the development of effective pain management strategies among athletes with SCI, future research should focus on developing knowledge products to improve awareness of common neuropathic pain descriptors among athletes with SCI and sports medicine personnel.

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.

Pain medication misuse in the South African spinal cord injury context

Background

Pain after spinal cord injury (SCI) is debilitating and has been reported to be difficult to treat, despite pharmacological interventions. Pain medication misuse (PMM) and associated individual factors among people with spinal cord injury (PWSCI) are scarce.

Aim

To determine PMM and the associated factors in PWSCI.

Setting

Homes of community-dwelling manual wheelchair users with SCI in South Africa.

Methods

Community-dwelling PWSCI (n = 122) were consecutively sampled and the Pain Medication Questionnaire (PMQ) was used to determine PMM. Descriptive statistics, Fisher's exact test, independent t-tests, and simple linear regression tests were performed using SPSS v27. Testing was conducted at the 0.05 level of significance.

Results

Eighty-five per cent of the participants reported the presence of pain and 48.1% of them used pain medication. Forty-four percent of people who used pain medication scored ≥ 30, indicative of serious aberrant drug-taking behaviours. Opioids were mainly used for neuropathic pain and in combination with other types of medications such as anticonvulsants and non-steroidal anti-inflammatories (44.0%). Pain severity and the type of pain medication were found to be predictors of PMM (p < 0.01 respectively).

Conclusion

Pain relief after SCI remains difficult to achieve, with an evident high risk of PMM, which may lead to long-lasting side effects, dependency, or overdose.

Contribution

This study has shown the need for the assessment of the potential risk of dependency before prescribing pain medication, particularly opioids to PWSCI.

'It becomes the new everyday life' - experiences of chronic pain in everyday life of people with limb-girdle muscular dystrophy

PURPOSE

To investigate experiences and reflections on challenges in everyday life of people living with limb-girdle muscular dystrophy (LGMD) and chronic pain in order to improve rehabilitation services.

MATERIALS AND METHODS

The design for this study was qualitative using the Interpretive Description methodology and the salutogenic theory of Sense of Coherence as the theoretical framework. Four semi-structured focus group interviews were conducted with 19 adults with LGMD from April to May 2021. The interviews were conducted online due to COVID-19.

RESULTS

Living with chronic pain and LGMD affected everyday life in terms of the participants' overall Sense of Coherence. Beneficial or unfavorable coping strategies were identified within four interrelated categorical themes: pain management, normality comprehension, affected emotional sentiment and altered identity.

CONCLUSION

Healthcare professionals should acknowledge possible chronic pain secondary to LGMD. Chronic pain appears to be a prevalent problem in people with LGMD with negative impact on everyday life, yet patients with LGMD did not receive sufficient information and necessary tools from health professionals to cope with chronic pain. Thus, adequate pain management appeared to be a difficult and self-taught process. Educating health professionals on how to support patients with LGMD and chronic pain is needed.IMPLICATIONS FOR REHABILITATIONHealth professionals should acknowledge and address the possibility of chronic pain secondary to limb-girdle muscular dystrophy (LGMD) and educate patients in pain management.Physiotherapy, energy management and engagement in meaningful activities may help patients gain some control of pain and limit the consequences of pain on everyday life.Supporting patients to accept pain and to shift focus towards their current capabilities may potentially improve pain management.Educating health professionals on how to support patients with LGMD and chronic pain is needed.

Associations Between Opioid Prescriptions and Use of Hospital-Based Services Among US Adults with Longstanding Physical Disability or Inflammatory Conditions Compared to Other Adults in the Medical Expenditure Panel Survey, 2010-2015

Purpose

To investigate the association of filling opioid prescriptions with healthcare service utilization among a nationally representative sample of adults with disability.

Materials and Methods

The Medical Expenditure Panel Survey (MEPS) for 2010-2015, Panels 15-19, was used to identify adults who were prescribed opioids during each two-year period. We examined the data for associations between opioid prescription filling and the number of emergency department (ED) visits and hospitalizations. The participants were grouped as those with inflammatory conditions or with longstanding physical disability, and a comparison group of those without these conditions.

Results and conclusions

Opioid prescription filling differed among adults with inflammatory conditions and longstanding physical disability compared to the comparison group (44.93% and 40.70% vs 18.10%, respectively). For both groups of people with disability, the relative rates for an ED visit or hospitalization were significantly higher for those who filled an opioid prescription, compared to adults with the same conditions who did not fill an opioid prescription. People with a longstanding physical disability who filled an opioid prescription had the highest rate ratio of ED use and hospitalization. Results from this investigation demonstrate that opioid prescription filling among persons with inflammatory conditions and longstanding physical disabilities is associated with higher rates of ED visits and hospitalizations.

Couples' experiences with sexuality after spinal cord injury

PURPOSE

To explore sexuality after spinal cord injury (SCI) from the perspectives of individuals with SCI and their romantic partners.

METHODS

A sample of 8 Canadian adults with SCI (6 men, 2 women) and their partners participated in this study (N = 16). Semi-structured dyadic and individual interviews were conducted, discussions surrounding sexuality and intimacy were extracted, and a qualitative description of the interview data was performed using thematic analysis.

RESULTS

Three major themes were identified: the changing definition of sex; emotions; and practical support. Couples' conversations around the changing definition of sex after SCI addressed the taboo topic of sexuality and the importance of communication between couples, peers, and healthcare providers. Emotions included fears of losing intimacy, embarrassment in managing bladder and bowel interference, and acceptance in balancing being a romantic partner and a caregiver. Finally, couples reported challenges accessing practical support including medical interventions and sexual health nurses, but saw value in peer mentorship programs.

CONCLUSION

Couples explored a changing definition of sex following SCI that was complicated by the taboo nature of discussing sexuality, experienced a range of emotions throughout the recovery process, and had difficulties navigating the healthcare system for appropriate support.IMPLICATIONS FOR REHABILITATIONHealthcare professionals should promote discussion and provide support for sexuality following SCI, but during initial rehabilitation may be too early.Healthcare providers should prepare people with SCI and their partners for the inevitable trial-and-error process involved in sexual rehabilitation.Rehabilitation professionals could direct couples to SCI peer mentorship programs to help normalize the experiences and emotions of sexual rehabilitation.

Exploration of the Experiences of Persons in the Traumatic Spinal Cord Injury Population in Relation to Chronic Pain Management

Chronic pain amongst individuals with traumatic and nontraumatic spinal cord injury (SCI) has high prevalence rates, with severe impact on the activities of daily living, mood, sleep and quality of life. This study aimed to explore the experiences and challenges of chronic pain management amongst the traumatic spinal cord injury (TSCI) population in the Western Cape region of South Africa. A qualitative descriptive approach was chosen for the study, in which 13 individuals living with TSCI were purposively recruited and interviewed telephonically. An inductive thematic analytic approach was used. The results indicate ineffectiveness of standard pain management, with a lack of education regarding pain physiology and pain management strategies as well as unbalanced decision-making between clinician and patient. Thus, patients develop coping strategies to survive with pain. Current pain regimes are suboptimal at best, underpinned by the lack of clarity or a mutually agreed plan to mitigate and eradicate pain. There is a need for chronic pain management beyond pharmacological prescription. Future practices should focus on adopting a holistic, biopsychosocial approach, which includes alternative pain therapy management. In addition, advances in pain management cannot be achieved without adopting a therapeutic alliance between the clinician and patient.

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

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

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.

Pain Reduction after Short Exposure to Virtual Reality Environments in People with Spinal Cord Injury

Emerging literature suggests that virtual reality (VR) may be a viable therapy for neuropathic pain (NP). This pilot study aimed to investigate the immediate effect of VR in reducing NP in people with spinal cord injury (SCI). Eight individuals with chronic NP after SCI were recruited and underwent consecutive exposure to scenery and somatic virtual environments (VE). The numeric rating scale (NRS) was used to assess pain before and after exposure to each VE. The Immersive Tendencies Questionnaire (ITQ) and Presence Questionnaire (UQO-PQ) were used to investigate the interaction between reported pain relief post-intervention with immersion and presence. There was a significant reduction in pain levels (5.1 ± 0.4, mean ± SEM) after short exposure to the scenery (3.1 ± 0.7, p = 0.04) and somatic VE (3.0 ± 0.7, p = 0.04), with no difference between intervention types (p = 0.56). There was a statistically significant negative correlation between the total ITQ score and the change in NRS after the scenery VR intervention (r_s = 0.743, p = 0.035). PQ scores showed no significant correlation with changes in pain following either intervention type. We found that short-term exposure to VR environments results in a reduction in chronic NP intensity in people with SCI.

Relationship between pain, fatigue, and physical activity levels during a technology-based physical activity intervention

Objective: The majority of individuals with spinal cord injury (SCI) experience chronic pain. Chronic pain can be difficult to manage because of variability in the underlying pain mechanisms. More insight regarding the relationship between pain and physical activity (PA) is necessary to understand pain responses during PA. The objective of this study is to explore possible relationships between PA levels and secondary conditions including pain and fatigue.Design: Prospective cohort analysis of a pilot study.Setting: Community.Participants: Twenty individuals with SCI took part in the study, and sixteen completed the study.Interventions: Mobile-health (mHealth) based PA intervention for two-months during the three-month study.Outcome measures: Chronic Pain Grade Scale (CPGS) questionnaire, The Wheelchair User's Shoulder Pain Index (WUSPI), Fatigue Severity Scale (FSS), and PA levels measured by the mHealth system.Results: A positive linear relationship was found between light-intensity PA and task-specific pain. However, the relationship between moderate-intensity PA and pain interference was best represented by a curvilinear relationship (polynomial regression of second order). Light-intensity PA showed positive, linear correlation with fatigue at baseline. Moderate-intensity PA was not associated with fatigue during any phase of the study.Conclusion: Our results indicated that PA was associated with chronic pain, and the relationship differed based on intensity and amount of PA performed. Further research is necessary to refine PA recommendations for individuals with SCI who experience chronic pain.Trial registration: ClinicalTrials.gov identifier: NCT03773692.

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.

The impact of neurological disability and sensory loss on mindfulness practice

OBJECTIVES

Mindfulness-based approaches are increasingly recommended in the management of medical conditions associated with sensory loss and absence, such as Spinal Cord Injury (SCI), Multiple Sclerosis (MS) and Functional Neurological Disorder (FND). Yet the implications of undertaking practices such as body scanning when living with sensory loss have not been considered. This study aimed to explore the impact of sensory loss on the practice and experience of mindfulness in qualified mindfulness teachers with SCI/FND/MS.

METHODS

Eight mindfulness teachers (5 females, 3 males) with SCI/FND/MS, sensory loss and wheelchair use were recruited from mindfulness teacher databases. In-depth, semi-structured interviews were undertaken, lasting between 50 and 93 min. Interviews were transcribed verbatim and analysed using Interpretative Phenomenological Analysis. Idiographic analyses for descriptive, linguistic and conceptual themes were completed before cross-case analyses.

RESULTS

Analyses resulted in two superordinate themes: (1) Adopting your Body; and (2) Sensation without Loss. These themes reflected the challenge of overcoming initial resistance to areas of the body with sensory disruption, building a relationship with the whole body, such that sensory awareness could be visualised and experienced without proprioception.

CONCLUSIONS

Mindfulness offers a unique approach to accepting and working with the body after paralysis or sensory loss. Fundamental to the use of mindfulness with such populations, is the prioritisation of inclusive sensory language and exploring sensory absence as well as sensory presence. The cognitive and emotional outcomes of body scanning may be uniquely elevated in populations with neurophysiological disorders, highlighting the benefits of mindfulness for adaptive and protective self-management.IMPLICATIONS FOR REHABILITATIONMindfulness-based practices which focus on the body and sensation are accessible to people with neurological limitations.Mindfulness techniques can be extended through the use of visualisation strategies to encourage (non-proprioceptive) awareness of paralysed limbs or areas of the body with sensory loss.The language used in mindfulness-based interventions may need adapted by practitioners so that it remains inclusive for people with sensory loss as well as sensory presence.Additional care needs to be taken when using body scans during mindfulness as they have the potential to exacerbate psychological distress in people with reduced sensory awareness.

Accessing healthcare as a person with a rugby-related spinal cord injury in South Africa: the injured player's perspective

Background: Rugby carries a risk for serious injuries, including acute spinal cord injuries. The lifetime health consequences of these injuries may be far-reaching.Purpose: In this study, we aimed to describe barriers and facilitators to healthcare and rehabilitation, in individuals with rugby-related spinal cord injuries in South Africa.Methods: This study adopted a pragmatic qualitative approach. Stratified purposive sampling was used to select interviews from players from a variety of socio-economic status and geographical areas for inclusion in this study. The final sample consisted of thirty-one (n = 31) participants. Thematic analysis was used to analyze the data.Results: Participants described long-term, accessible, affordable, quality healthcare and rehabilitation as important contributors to their quality of life. Even though public healthcare is accessible from a cost point of view, quality of care, availability of rehabilitation services and factors such as affordability and availability of adequate transport remain a barrier for lower socio-economic groups.Conclusion: This population was unique, as the support from a dedicated organization enabled participants to overcome some barriers, highlighting the challenges of the healthcare system in maintaining the health of people with spinal cord injuries. Every effort should be made to create equitable access to healthcare and rehabilitation for persons with spinal cord injuries in South Africa.

Inducing positive emotions to reduce chronic pain: a randomized controlled trial of positive psychology exercises

PURPOSE

Positive emotions have been found to be analgesic and can be induced by positive psychology exercises. This study tested if positive psychology exercises provide beneficial effects on pain, responses to pain, physical (pain interference), and emotional function.

METHODS

Randomized parallel-group controlled single-blinded superiority-trial including community-dwelling individuals with chronic pain secondary to spinal cord injury. Participants in the intervention group were instructed to practice 4 personalized positive psychology exercises for 8 weeks. Participants in the control group were asked to be mindful and write about current life events.

RESULTS

108 (64%) completed the study. At post-treatment, the intervention participants reported significant reductions in pain intensity and improvements in pain catastrophizing and pain control, relative to baseline. Both groups reported significant decreases in pain interference and negative emotions. Significant between-group differences emerged for pain intensity at post-treatment. At 3-months follow-up, improvements maintained for the intervention group and improvements in positive emotions reached statistical significance. Between-group differences were identified for pain intensity at post-treatment.

CONCLUSION

Positive psychology exercises represent a potential effective complementary treatment that result in benefits on pain which can be readily implemented into daily living. Trials designed with an inactive control condition should be conducted to further address efficacy.

TRIAL REGISTRATION

Swiss ethics committee (EKNZ 2014-317)/clinicaltrials.gov (NCT02459028) Registration date: Ethics approval 25.10.2014/Study start date: May 2015 URL of the record: https://clinicaltrials.gov/ct2/show/NCT02459028?term=NCT02459028&cntry=CH&draw=2&rank=1IMPLICATIONS FOR REHABILITATIONPain engenders negative emotions (e.g., fear, anger, sadness) which can negatively affect psychological, social, and physical function.Positive emotions have been found to be analgesic and can be induced by practicing positive psychology exercises.The findings of the current randomized controlled trial provide support for practicing positive psychology exercises (beyond the effects of pain medication intake), in particular on the reduction of pain intensity, but also in improving pain catastrophizing and pain control.The majority of the positive psychology exercises are brief and self-administered positive activities that have no known negative side effects nor financial cost, can be tailored to a person's preferences in activities and can be readily implemented into daily living with chronic pain, complementing standard treatment of pain.

"Challenges and facilitators-navigating in the landscape of spinal cord injury neuropathic pain"-a qualitative study on the use of prescribed drugs

STUDY DESIGN

A qualitative study with an emergent design using semi-structured interviews in focus groups.

OBJECTIVES

To explore the expectations, experiences and desires among individuals who are prescribed drugs for spinal cord injury (SCI) neuropathic pain (NP).

SETTING

SCI rehabilitation centre.

METHODS

Eighteen informants with SCI and NP were enrolled. The informants originated from large and small cities in southern Sweden. Data were collected in focus groups consisting of 4-5 individuals in four separate sessions. An emergent design was employed using an interview guide containing open questions. The interviews were transcribed verbatim and data were analyzed according to qualitative content analysis.

RESULTS

A model of three themes emerged: "Balancing between pain and side-effects" described the difficult choices the informants had to make between drugs and their unwanted side-effects and pain, "Desiring competence and structure in pain management" described the informants wishes regarding pain management and "From hope to personal solutions" described the process from hope of total pain relief from drugs to the development of personal strategies.

CONCLUSIONS

There is a great need for improvement of SCI-related neuropathic pain management since recommended drugs are insufficiently effective and accompanied by severe side-effects that impact quality of life but also due to structural limitations and physicians' lack of competence in pain management.

Spinal cord injury pain

Spinal cord injury pain encompasses musculoskeletal and neuropathic pain. Its management is often multidisciplinary and involves specific drugs such as antidepressants and antiepileptics, and nonpharmacological treatment including psychotherapy, physical therapy and neuromodulation techniques. Recent progress in the diagnosis, assessment, and understanding of its mechanisms offers the perspective of a more rational therapeutic management, which should result in better therapeutic outcome.

An exploration of attitudes and preferences towards medications among healthcare providers and persons with spinal cord injury/dysfunction: a qualitative comparison

PURPOSE

To compare the attitudes and preferences of persons with spinal cord injury/dysfunction (SCI/D) and healthcare providers regarding prescription medications, over-the-counter medications, and natural health products (NHPs).

MATERIALS AND METHODS

A qualitative study involving semi-structured interviews with healthcare providers (n = 32) and persons with SCI/D (n = 19) in Canada. Inductive descriptive and interpretive analyses were conducted using data display matrices and a constant comparative approach.

RESULTS

Participants described differing perceptions of therapeutic benefits based on medication type, with shared attitudes about the therapeutic benefits of prescription medications and differing views about the effectiveness of NHPs. Despite the perceived effectiveness of prescription medications, persons with SCI/D preferred to avoid them due to concerns about side effects, safety, and stigma. Persons with SCI/D were often concerned about the long-term safety of prescription medications, whereas providers focused more on medication-related addictions. Participants discussed stigma relating to prescription medications, NHPs, and medicinal marijuana.

CONCLUSION

Healthcare providers and persons with SCI/D described different attitudes about and preferences for pharmacotherapeutic products, contributing to challenges in optimizing medication management. Strategies to improve medication management include shared decision-making to incorporate patient preferences into care plans and explicit discussions about long-term medication safety. Further, steps are needed to combat the stigma associated with medication use.Implications for rehabilitationFollowing a person-centered approach to shared decision-making, prescribers should initiate explicit conversations about patient medication preferences, short and long-term prescription medication side effects, and alternative treatment options.Regarding prescription medication safety, persons with spinal cord injury/dysfunction focused on the long term impact of medications, while providers focused on medication-related addictions, highlighting a disconnect that should be discussed during initiation, continuation, or discontinuation of a medication.Providers should be mindful of the stigma associated with taking multiple prescription medications, including medicinal marijuana, as well as the stigma associated with over-the-counter medications and natural health products.Providers could benefit from education about spinal cord injury/dysfunction-specific prescription medications and could benefit from increased education about natural health products.

"No one wants you" - a qualitative study on the experiences of receiving rejection from tertiary care pain centres

Background and aims Four out of 10 referrals to tertiary care pain centres in Norway are not granted pain centre treatment, confirming earlier research on that this group of patients struggle to access the highest standard of care. Still, no study investigating how people with chronic pain experience rejections from pain centres was found. The aim of the study was therefore to investigate how people with chronic pain experience receiving a rejection from tertiary care pain centres after being referred by their general practitioners (GPs). Methods This was a qualitative study with semi-structured individual interviews with 12 persons, seven men and five women, rejected from the four different pain centres in Norway. The data were analysed thematically using systematic text condensation. Results The pain centre rejection created strong reactions, partly because the rejection was perceived as a refusal from the health care system as a whole. This was especially so because the pain centre was regarded as the last remaining treatment option, and given the rejection, they were now declined help by the experts in the field. Even though some informants had received an explanation for why they had not been granted pain centre treatment, a prominent experience was that the informants found it difficult to understand why their referral had been rejected given the severity of their pain. The incomprehensibility of the rejection together with a feeling of lack of future treatment options, increased the hopelessness and frustration of their situation and made it challenging to move on and search for help elsewhere. Conclusions The experiences with the pain centre rejections indicate that the rejection can have grave consequences for each individual in the following months. An improved system for how to handle expectations towards referrals, including prepare for the possibility of rejection and how to follow up a rejection, seems warranted. Implications Because a pain centre rejection most likely is received by persons in a vulnerable position, there should be available health care services to help them understand the rejections. And furthermore, help them to move from disappointment and hopelessness, towards an experience of empowerment and reorientation, by for instance planning further actions and interventions, and thereby, acknowledge their need for help.

Massage therapy treatment and outcomes in a patient with Charcot-Marie-Tooth disease: A case report

BACKGROUND

Charcot-Marie-Tooth (CMT) disease, a progressive hereditary peripheral neuropathy, leads to muscle weakness, wasting, and sensory and motor nerve deprivation. The two main types of CMT are CMT1 (demyelinating) and CMT2 (axonal). Initial findings include foot deformities and sensory changes with progression to altered gait, diminished reflexes, and muscle wasting and weakness. Treatment is aimed at reducing symptoms with physiotherapy, orthotics, splints, braces, fatigue and pain management and possible surgical intervention. Research is limited on the effects of massage or other complementary and alternative medicines (CAM) on CMT.

OBJECTIVE

To determine whether massage therapy would aid in reducing bilateral foot and lumbar pain and increasing lumbar range of motion (ROM) in a CMT patient.

METHOD

A 44-year-old male with CMT presented with lumbar and bilateral foot pain, and foot deformities. Treatment aims were to decrease lumbar and foot pain and increase lumbar ROM. A tape measure was used to measure lumbar flexion and extension pre- and post-treatment. The Numerical Rating Scale (NRS) was used to evaluate foot and lumbar pain intensity before and after each treatment. Rhythmical superficial touch, myofascial release, and petrissage techniques were applied to the back, legs, and neck. A massage therapy student provided treatments over seven weeks.

RESULTS

Bilateral foot and lumbar pain decreased and lumbar flexion and extension increased post-treatment, and overall. All other lumbar movements increased overall.

CONCLUSION

Massage therapy may positively affect pain intensity and ROM associated with CMT. Future studies linking massage therapy and CMT are needed.

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.

Using ecological momentary assessment to evaluate neuropathic pain experienced by adults with SCI: recommendations and participant perceptions

PURPOSE

Neuropathic pain is a debilitating consequence of spinal cord injury. Ecological momentary assessment can be a valuable research tool for understanding temporal fluctuations in neuropathic pain and designing effective management strategies. The objectives of this study were to (a) describe strategies necessary to adapt ecological momentary assessment to measure neuropathic pain in adults with spinal cord injury, and (b) explore participant perceptions of using ecological momentary assessment to measure pain sensations.

METHODS

End-users with spinal cord injury provided input to guide development of an ecological momentary assessment protocol. Six adults with spinal cord injury (ages 27-50 years, M = 39.33 ± 8.24) engaged in the six-day protocol and completed six daily neuropathic pain assessments. Upon finishing participants completed a semi-structured interview regarding their protocol experiences. A qualitative content analysis was used to analyze the interview data.

RESULTS

Participants reported that this specific ecological momentary assessment protocol was unobtrusive to their daily routines, and effectively captured their neuropathic pain sensations. However, participants experienced increased neuropathic pain due to the repeated nature of assessments.

CONCLUSION

Ecological momentary assessment can capture the dynamic nature of neuropathic pain experienced by persons with spinal cord injury. However, caution should be taken when designing intensive pain-related protocols to minimize pain exacerbation.IMPLICATIONS FOR REHABILITATIONNeuropathic pain affects up to 75% of people with spinal cord injury and is one of the most frequently occurring, debilitating forms of pain.Appropriate and feasible pain data collection methods are necessary to acquire a better understanding of how neuropathic pain manifests in people with spinal cord injury.Implementing ecological momentary assessment in a rehabilitation setting may help facilitate the monitoring of neuropathic pain for both rehabilitation professionals and persons with SCI.Using ecological momentary assessment may lead to a better understanding of individual temporal patterns of neuropathic pain that could inform the design of tailored neuropathic pain management techniques.

A cohort study of the association between psychosocial factors and pain in patients with Spinal Cord Injury and Stroke

PURPOSE

To explore associations between psychosocial factors and pain intensity and pain interference in a population with a new neurological injury on admission to rehabilitation, and after six months.

MATERIALS AND METHODS

A longitudinal, prospective cohort study with participants with stroke or Spinal Cord Injury (SCI) completing questionnaires for pain intensity and interference, mental health, pain coping strategies and pain attitudes and beliefs within two weeks of admission to inpatient rehabilitation. After six months, participants completed measures of pain intensity and pain interference only.

RESULTS

In all 32 participants completed the questionnaires at baseline and 19 after six months. Several associations between a person's mental health and certain beliefs were associated with pain outcomes. Additionally, poorer baseline mental health was associated with greater pain intensity and pain interference after six months, and a stronger belief in a medical cure for pain at baseline was associated with less pain intensity and pain interference after six months.

CONCLUSIONS

Psychosocial factors are associated with pain early after stroke and SCI. Psychosocial factors are also associated with pain outcomes several months after stroke and SCI. This highlights the importance of psychosocial factors in both of these populations and their relationship with pain outcomes.

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.

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.

Self-management of pain and depression in adults with spinal cord injury: A scoping review

Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.

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

REVIEW QUESTION/OBJECTIVE

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

Measuring pain phenomena after spinal cord injury: Development and psychometric properties of the SCI-QOL Pain Interference and Pain Behavior assessment tools

OBJECTIVE

To develop modern patient-reported outcome measures that assess pain interference and pain behavior after spinal cord injury (SCI).

DESIGN

Grounded-theory based qualitative item development; large-scale item calibration field-testing; confirmatory factor analyses; graded response model item response theory analyses; statistical linking techniques to transform scores to the Patient Reported Outcome Measurement Information System (PROMIS) metric.

SETTING

Five SCI Model Systems centers and one Department of Veterans Affairs medical center in the United States.

PARTICIPANTS

Adults with traumatic SCI.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Spinal Cord Injury - Quality of Life (SCI-QOL) Pain Interference item bank, SCI-QOL Pain Interference short form, and SCI-QOL Pain Behavior scale.

RESULTS

Seven hundred fifty-seven individuals with traumatic SCI completed 58 items addressing various aspects of pain. Items were then separated by whether they assessed pain interference or pain behavior, and poorly functioning items were removed. Confirmatory factor analyses confirmed that each set of items was unidimensional, and item response theory analyses were used to estimate slopes and thresholds for the items. Ultimately, 7 items (4 from PROMIS) comprised the Pain Behavior scale and 25 items (18 from PROMIS) comprised the Pain Interference item bank. Ten of these 25 items were selected to form the Pain Interference short form.

CONCLUSIONS

The SCI-QOL Pain Interference item bank and the SCI-QOL Pain Behavior scale demonstrated robust psychometric properties. The Pain Interference item bank is available as a computer adaptive test or short form for research and clinical applications, and scores are transformed to the PROMIS metric.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

A Canadian Survey of Self-Management Strategies and Satisfaction with Ability to Control Pain: Comparison of Community Dwelling Adults with Neuropathic Pain versus Adults with Non-neuropathic Chronic Pain

BACKGROUND

Individuals with chronic pain with neuropathic characteristics (CPNC) describe a different pain experience compared with those with chronic pain without neuropathic characteristics (CP).

AIMS

The aim of this study was to describe and compare pain, self-management strategies, and satisfaction with ability to control pain between adults with CPNC versus CP.

PARTICIPANTS

Seven hundred and ten community-dwelling adults with chronic pain participated in a cross-sectional survey.

METHODS

CPNC was defined as a score ≥12 on the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. Self-management and pain control was compared between participants with CPNC and CP using frequency, percent, relative risk (RR), odds ratios (ORs), and 95% confidence intervals (CIs).

RESULTS

Participants with CPNC (188/710) reported lower socioeconomic status, poorer general health, and more intense, frequent, and widespread pain. They were more likely to use prescription medications to manage pain (adjusted OR = 2.25, CI = 1.47-3.42). They were more likely to use potentially negative strategies to ease the emotional burden of living with chronic pain, including substance use (adjusted OR = 1.58, CI = 1.06-2.35), denial (adjusted OR = 2.21, CI = 1.49-3.28), and behavioral disengagement (adjusted OR = 1.68, CI = 1.16-2.45), and they were more likely to be completely dissatisfied with their ability to control pain (RR = 1.77, CI = 1.21-2.58).

CONCLUSIONS

Individuals with CPNC have distinct pain and self-management experiences compared with those with CP that may lead to negative coping strategies and dissatisfaction with ability to control pain. Therefore, self-management assessment and support should be tailored by pain condition.

Neuropathic pain in a rehabilitation setting after spinal cord injury: an interpretative phenomenological analysis of inpatients' experiences

Study design

Qualitative, semi-structured interviews.

Objectives

Neuropathic pain (NP) can be psychologically and physically debilitating, and is present in approximately half of the spinal cord injured (SCI) population. However, under half of those with NP are adherent to pain medication. Understanding the impact of NP during rehabilitation is required to reduce long-term impact and to promote adherence to medication and psychoeducation recommendations.

Setting

United Kingdom.

Methods

Five males and three females with SCI and chronic NP, resident in rehabilitation wards at a specialist SCI center in the United Kingdom, took part. Semi-structured interviews were conducted with participants less than 15 months post-SCI (mean = 8.4 months). Verbatim transcripts were subject to interpretative phenomenological analysis (IPA).

Results

Three super-ordinate themes were identified, mediating pain and adherence: (1) the dichotomy of safety perceptions; (2) adherence despite adversity; and (3) fighting the future. Analyses suggest that experience of the rehabilitation setting and responsiveness of care shapes early distress. Attitudes to medication and psychosocial adjustment are relevant to developing expectations about pain management.

Conclusions

Enhancing self-efficacy, feelings of safety in hospital, and encouraging the adoption of adaptive coping strategies may enhance psychosocial and pain-related outcomes, and improve adherence to medication. Encouraging adaptive responses to, and interpretation of, pain, through the use of interventions such as coping effectiveness training, targeted cognitive behavioral pain management, and acceptance-based interventions such as mindfulness, is recommended in order to reduce long-term reliance on medication.

Expectations of persons with paraplegia regarding their care in India: a qualitative study

STUDY DESIGN

A qualitative study.

OBJECTIVE

The aim of this study was to understand expectations of persons with paraplegia in India regarding their care.

SETTING

India.

METHODS

This study used a qualitative methodology to have a focus group interview of persons with paraplegia in India. Focus group consisted of two to four participants with paraplegia. Adults with level T6 and below, complete injury, duration of at least 6 months post injury and those living in the community were included. Online focus group interviews were conducted using ZOOM online software for online discussions/meetings. Data were collected till data saturation. Recorded videos were transcribed into texts, and the transcribed documents were analysed using the ATLASti.8 software for qualitative data analysis.

RESULTS

Forty-eight codes were retrieved under fourteen code groups. These code groups were acceptance, accessibility, advanced technology, assistive devices, basic skills, employment, expectations, experiences, functional independence, government policies, knowledge, psychological make-up, physiotherapy and rural area.

CONCLUSION

Because of lack of awareness, knowledge and education provided to persons with paraplegia, their expectations were often unrealistic. Patient education and education of the health professionals are two of the most important aspects in spinal cord injury rehabilitation that must be taken into consideration in India.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A qualitative exploration of living with chronic neuropathic pain after spinal cord injury: an Italian perspective

PURPOSE

The purpose of this study is to understand how people with spinal cord injury (SCI) in Italy experienced and managed chronic neuropathic pain (CNP), and their perspectives of Italian healthcare services.

METHOD

Nine people with SCI participated. Two focus groups (three and four individuals) and one semi-structured interview were audio-recorded and transcribed. One "virtual interview" was conducted via e-mail. A qualitative thematic analysis was undertaken.

RESULTS

Three main themes were identified. First, participants experienced pain as a powerful, intrusive and, at times, inescapable force, with the potential to overwhelm the sense of self, and place limits on enjoyable experiences. Second, participants recounted a strong desire to understand CNP, and, in the absence of expert guidance, used trial-and-error methods to find ways of relieving pain. Third, healthcare practice was perceived as pharmacologically focused and lacking specialist knowledge. Practitioners were described as reluctant to explore alternative therapies or participate in collaborative, patient-centred care.

CONCLUSIONS

This study reveals SCI-related CNP as a deeply troubling and psychologically distressing condition impacting widely on everyday life. Specialist, collaborative, individually tailored rehabilitation approaches that attend to patients' priorities and experiences, include education about CNP, and offer opportunities to explore complementary treatments, may be welcomed by people living with this condition in Italy. Implications for Rehabilitation People living in Italy with SCI-related CNP describe inadequate and ineffective pain relief. The impact of CNP on physical, psychological and social functioning is significant but may be an issue that continues to be underestimated by health professionals. Health professionals may better support patients living in Italy with SCI-related CNP by providing long-term, individualized, collaborative and specialist support. Ongoing, patient-led discussion forums where experiences, ideas and information can be shared may be useful to persons with SCI to help them cope with their pain over the long-term.

Qualitative meta-synthesis: the experience of chronic pain across conditions

AIM

To synthesize qualitative descriptions of the experience of chronic pain across conditions.

BACKGROUND

Chronic pain is a transdiagnostic symptom in that while somatic pathology plays a role in activating pain pathways, psychological and social factors contribute to the experience of pain over time. The treatment of the underlying condition may require both biomedical intervention and biopsychosocial approaches.

DESIGN

Qualitative meta-synthesis using Confidence in the Evidence from Reviews of Qualitative Research (CERQual) developed by Grading of Recommendations Assessment Development and Evaluation (GRADE) working group to evaluate the strength of the evidence.

DATA SOURCES

PubMed and Ovid Medline from 2000-2015.

REVIEW METHODS

Following a systematic search strategy all papers were assessed in relation to inclusion criteria and quality. Themes were extracted from each study and a meta-synthesis conducted before completing an evaluation of confidence in the findings.

RESULTS

Forty-one papers exploring the experience of chronic pain were included in the review. Five meta-themes were identified across the studies: 1) the body as obstacle; 2) invisible but real; 3) disrupted sense of self; 4) unpredictability; and 5) keeping going. There was high confidence in the evidence for three themes: 'the body as obstacle'; 'disrupted sense of self' and 'keeping going'; and moderate confidence in the evidence for 'invisible but real' and 'unpredictability'.

CONCLUSIONS

The findings in this review suggest there are similarities in the experience of chronic pain across a range of conditions that have implications for the development of transdiagnostic pain management strategies and interventions.

Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain

BACKGROUND AND AIMS

Pain is one of the most common reasons for patients to seek primary health care. Pain relief is likely to be achieved for patients suffering from acute pain, but for individuals with chronic pain it is more likely that the condition will persist. These patients have the option of being referred to specialised pain clinics. However, the complexity surrounding chronic pain patients is not well studied in these settings. This study aimed to describe patients with chronic pain referred to a pain clinic by using the information submitted during their first visit and one year later and also to identify associations between baseline characteristics and improvements in health-related quality of life in the follow-up.

METHODS

This was a longitudinal observational study of a sample consisting of 318 patients referred to a pain clinic. One group of patients containing 271 individuals (median age 48, 64% females) was assessed and received conventional pain treatment (CPT group) and a second group of 47 patients (median age 53, 64% females) was assessed by a pain specialist and referred back to their physician with a treatment recommendation (assessment only, AO group). Patient-reported outcome measures in health-related quality of life (EQ-5D), pain intensity (VAS), mental health (HADS), insomnia (ISI), pain-related disability (PDI), kinesiophobia (TSK) and sense of coherence (SOC) were collected at the first visit and one year later.

RESULTS

At baseline, the CPT group reported a low EQ-5D Index (median (md) 0.157) and EQ VAS (md 40) as well as considerable high, current pain intensity VAS (md 58), HADS anxiety (md 8), ISI (md 17), PDI (md 36) and TSK (md 39). The AO group showed similar problems (no significant differences compared to the CPT group), except for ISI, where the AO group reported less severe problems. At the one-year follow-up, the CPT group had a statistically significant improvement in EQ-5D, VAS, ISI, PDI and TSK. In the AO group no significant changes were observed. In the CPT group there was an association between a high ISI level at baseline and an improved EQ-5D Index in the follow-up.

CONCLUSIONS

The study describes rarely explored groups of patients with chronic pain at a pain clinic. Severe pain problems were present in both groups at their first visit. A statistically significant improvement could be seen in the group that was conventionally treated while this was not the case among those subjects who were assessed and referred. The results imply, that relatively limited treatment strategies were helpful for the patients' health-related quality of life. Despite these improvements, the patients were not fully recovered, pointing to the chronicity of pain conditions and the need of support for many patients.

IMPLICATIONS

Increased knowledge about assessment, selection and treatment at pain clinics is important to improve the quality of the work performed at these clinics. Despite limited resources, further efforts should be made to collect comparable, valid data on a regular base from pain clinics in order to develop recommendation models.

The injury trajectory for young people 16-24 years in the six months following injury: A mixed methods study

BACKGROUND

Adolescents and young people are the population at greatest risk of injury and therefore injury-related mortality and morbidity. Inquiry into the injury trajectory of young people is needed to identify this group's specific needs for healthcare. This paper reports the integration of quantitative and qualitative findings from a sequential explanatory mixed methods study examining young people aged 16-24 years' experience and trajectory of traumatic physical injury in the initial six months. The aim of integration was to address the question: In what ways are injured young peoples' experiences and self-management during the initial six months of the injury trajectory impacted by their injury, family support, and provision of healthcare?

METHODS

Key findings from epidemiological datasets on young person injuries from hospital and coronial databases (Phase 1) were combined with key findings from qualitative interviews with 12 injured young people and 10 family members (Phase 2).

RESULTS

The integration of findings from Phase 1 and Phase 2 resulted in three new findings; [1] (Alfred Health, 2014). A young person's perception of the severity of their injury, as well as the amount of time spent in hospital, impacts substantially on the way in which they experience injury, and this is managed differently between genders; [2] (Newnam et al., 2014). Admission to an Intensive care unit, including the intensity and duration of care, is the primary influence on how a family will provide support to the young person in the inpatient period; and [3] (Lyons et al., 2010). Young people's perception and understanding of their recovery from injury is in contrast with how healthcare systems are structured to provide rehabilitation and recovery care.

CONCLUSION

The injury trajectory and recovery process of young people in the six months following injury have been have conceptualised. These trajectories of recovery can inform the development of anticipatory guidance frameworks for clinicians and guide the provision of and planning for clinical services for injured young people.

The barriers, benefits and facilitators of leisure time physical activity among people with spinal cord injury: a meta-synthesis of qualitative findings

Physical activity (PA) can have a positive impact upon health and well-being for people with spinal cord injury (SCI). Despite these benefits, people with SCI are within the most physically inactive segment of society that comprises disabled people. This original meta-synthesis of qualitative research was undertaken to explore the barriers, benefits and facilitators of leisure time physical activity (LTPA) among people with SCI. Articles published since 2000 were identified through a rigorous search of electronic databases, supported with a hand search of relevant journals and papers. In total, 64 papers were read in full, and based on inclusion criteria, 18 were relevant for review. The key themes constructed from the data were summarised, compared and synthesised. Eight interrelated concepts were identified as barriers, benefits and/or facilitators of LTPA: (i) well-being (WB); (ii) environment; (iii) physical body; (iv) body-self relationship; (v) physically active identity; (vi) knowledge; (vii) restitution narrative; (viii) perceived absences. Based on the synthesised evidence, healthcare professionals need to appreciate the relationships between the barriers, benefits and facilitators of LTPA in order to successfully promote a physically active lifestyle. Equally, a more critical attitude to PA promotion is called for in terms of possible adverse consequences.

Patients' perspectives on pain

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

Considerations for neuropathic pain conditions in life care planning

Significant progress has been made in assessing and managing neuropathic pain. Newer, more effective treatments with minimal side effects are available. Despite advances in treatments, neuropathic pain remains a multifaceted phenomenon that can be difficult to alleviate. Diagnosis, mechanisms of injury, and treatment recommendations are critical components of life care plans for patients with neuropathic pain. A clear understanding of the underlying issues and careful coordination with neurologists and other treatment providers are key to providing optimal life care plans. Understanding that pain treatments vary over time and by individual patient is integral to comprehensive life care planning.