Needs and requests – patients and physicians voices about improving the management of spinal cord injury neuropathic pain

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.

Development of a pain education resource for people with spinal cord injury

Many people with spinal cord injury (SCI) develop chronic pain, including neuropathic pain. Unfortunately, current treatments for this condition are often inadequate because SCI-associated neuropathic pain is complex and depends on various underlying mechanisms and contributing factors. Multimodal treatment strategies including but not limited to pharmacological treatments, physical rehabilitation, cognitive training, and pain education may be best suited to manage pain in this population. In this study, we developed an educational resource named the SeePain based on published pain literature, and direct stakeholder input, including people living with SCI and chronic pain, their significant others, and healthcare providers with expertise in SCI. The SeePain was then 1) systematically evaluated by stakeholders regarding its content, comprehensibility, and format using qualitative interviews and thematic analysis, and 2) modified based on their perspectives. The final resource is a comprehensive guide for people with SCI and their significant others or family members that is intended to increase health literacy and facilitate communication between SCI consumers and their healthcare providers. Future work will quantitatively validate the SeePain in a large SCI sample.

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.

A six-participant pilot single-subject study of an individualized pain management program for people with spinal cord injury

STUDY DESIGN

Single-subject repeated measures design.

OBJECTIVES

To explore the impacts of a novel individualized interdisciplinary pain self-management program for persons living with spinal cord injury pain.

SETTING

A large rehabilitation institute for adults with physical disabilities in Quebec city (Quebec, Canada).

METHODS

Six persons having sustained a spinal cord injury and experiencing chronic pain participated. Following a five-week pre-intervention phase (baseline repeated measures) and a clinical evaluation, individualized intervention objectives were developed in collaboration with each participant. Then, participants completed a ten-week intensive intervention and a six-month consolidation phase. The program included cognitive behavioral therapy, and physical and pharmacological interventions, which were group- and individual-based. Outcome measures were the Canadian Occupational Performance Measure (COPM), the French-Canadian Chronic Pain Self-efficacy Scale (FC-CPSES), the Brief Pain Inventory (BPI), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

For five out of the six participants, a majority of outcomes improved during either of the intervention phases or both. Improvements in occupational performance were clinically significant for three participants. Pain interference and anxiety improved significantly in five participants, while pain self-efficacy and depressive symptoms improved in four participants.

CONCLUSIONS

The results suggest that the pain self-management program was effective to reduce the impact of spinal cord injury pain. Further research is needed to replicate these results in a larger study and comprehend the factors favoring or undermining improvements with such programs, as well as their persistence over time.

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.

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

OBJECTIVE

Persistent neuropathic pain is a common and often severe consequence of spinal cord injury (SCI). There is a critical need to better understand how to overcome barriers and promote facilitators to optimal pain management. The present study was designed to identify, from the perspectives of persons living with SCI, their significant others, and SCI health care professionals, the barriers and facilitators to optimal pain management for intense neuropathic pain.

DESIGN

Qualitative interviews.

SETTING

University laboratory.

SUBJECTS

People with SCI who had experienced intense neuropathic pain for a minimum of a year (N = 15), their significant others (N = 15), and SCI health care providers (N = 15).

METHODS

Qualitative interviews were recorded, transcribed, and analyzed based on grounded theory using ATLAS.ti software.

RESULTS

Inadequate access to care, information, or pain management expertise were frequently perceived barriers to optimal pain management across all three groups. Another major barrier was SCI stakeholders' concerns regarding the risks of adverse effects and addiction to pain medication. Facilitators included having a better understanding of pain and available treatment options, effective patient-provider communication, resilience, and access to nonpharmacological treatment options.

CONCLUSIONS

Managing intense neuropathic pain poses significant challenges after SCI. SCI stakeholders felt that accessible treatment options were limited and primarily focused on pain medications with minimal benefit but with significant risks for addiction and adverse effects. Actionable facilitators to optimal pain management after SCI include education regarding neuropathic pain and treatment options for all stakeholders, better communication regarding neuropathic pain among stakeholders, and improved patient access to nonpharmacological treatment options.

"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.

Impact of neuropathic pain on participation: perspectives from the Canadian SCI community survey

STUDY DESIGN

Secondary analysis of an observational cohort study.

OBJECTIVES

To determine if the perceived overall limitation of neuropathic pain on activities (NP limitation) covaries in 26 specific life activities in people with SCI, taking into account the severity of injury.

SETTING

Community-based in Canada.

METHODS

Secondary analysis of a cohort (N = 1481) was performed using questionnaires to rate NP frequency and limitation on activities as well as participation in 26 life activities. Relative risks (RR) analyses using Poisson regression were used to examine the data.

RESULTS

Most participants (N = 1158; 78%) reported living with NP (from once a year to every day). When NP limitation was described as "not at all" or "very little" (N = 394; 34%), there was no statistically significant RR (p > 0.0019), suggesting no additional risk of not participating "as much as wanted" in any of activities compared to participants with no NP. When NP limitation was described as "to some extent" (N = 411; 35%), a significantly higher risk was observed for 5 of the 26 activities (1.34 < RR < 1.62), and for 23 activities with a large range (1.24 < RR < 3.20) when NP limitation was rated as "to a great extent or more" (N = 353; 31%).

CONCLUSION

The variation of RR observed across the 26 activities suggests that the NP limitation may not be general but rather related to specific activity characteristics, which should be taken into account when evaluating NP limitations with a specific focus on the life activities being affected.

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.

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.

[Pain in patients with paraplegia]

Chronic pain is one of the most reported health problems in patients suffering from spinal cord injuries and is described by the patients as one of the most burdensome sequelae of paraplegia. Various types of pain, such as nociceptive, neuropathic and other types of pain can occur. In addition, multiple pathophysiological mechanisms based on the biopsychosocial pain model play a role in the origins of the pain. These aspects necessitate a multimodal pain management approach in this patient group. This article presents an overview of the occurrence, importance and pathophysiology of chronic pain following spinal cord injury as well as diagnostic and therapeutic approaches.

Evaluation of a specialized yoga program for persons with a spinal cord injury: a pilot randomized controlled trial

Objectives

The purpose of this randomized controlled trial was to evaluate the effects of a specialized yoga program for individuals with a spinal cord injury (SCI) on pain, psychological, and mindfulness variables.

Materials and methods

Participants with SCI (n=23) were outpatients or community members affiliated with a rehabilitation hospital. Participants were randomized to an Iyengar yoga (IY; n=11) group or to a 6-week wait-list control (WLC; n=12) group. The IY group participated in a twice-weekly 6-week seated IY program; the WLC group participated in the same yoga program, after the IY group’s yoga program had ended. Pain, psychological, and mindfulness measures were collected at two time points for both groups (within 1–2 weeks before and after program 1 and at a third time point for the WLC group (within 1 week after program 2).

Results

Linear mixed-effect growth models were conducted to evaluate the main effects of group at T2 (postintervention), controlling for T1 (preintervention) scores. T2 depression scores were lower (F_1,18=6.1, P<0.05) and T2 self-compassion scores higher (F_1,18=6.57, P< 0.05) in the IY group compared to the WLC group. To increase sample size and power, the two groups were combined and analyzed across time by comparing pre- and postintervention scores. Main effects of time were found for depression scores, (F_1,14.83=6.62, P<0.05), self-compassion, (F_1,16.6=4.49, P<0.05), mindfulness (F_1,16.79=5.42, P<0.05), mindful observing (F_1,19.82=5.06, P<0.05), and mindful nonreactivity, (F_1,16.53=4.92, P<0.05), all showing improvement after the intervention.

Discussion

The results indicated that a specialized 6-week yoga intervention reduced depressive symptoms and increased self-compassion in individuals with SCI, and may also have fostered greater mindfulness.

The Development, Description and Appraisal of an Emergent Multimethod Research Design to Study Workforce Changes in Integrated Care Interventions

Introduction:

In this paper, we provide a detailed and explicit description of the processes and decisions underlying and shaping the emergent multimethod research design of our study on workforce changes in integrated chronic care.

Theory and methods:

The study was originally planned as mixed method research consisting of a preliminary literature review and quantitative check of these findings via a Delphi panel. However, when the findings of the literature review were not appropriate for quantitative confirmation, we chose to continue our qualitative exploration of the topic via qualitative questionnaires and secondary analysis of two best practice case reports.

Results:

The resulting research design is schematically described as an emergent and interactive multimethod design with multiphase combination timing. In doing so, we provide other researchers with a set of theory- and experience-based options to develop their own multimethod research and provide an example for more detailed and structured reporting of emergent designs.

Conclusion and discussion:

We argue that the terminology developed for the description of mixed methods designs should also be used for multimethod designs such as the one presented here.

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.

Living With Chronic Pain After Spinal Cord Injury: A Mixed-Methods Study

OBJECTIVE

To identify the relative importance of positive (facilitators) and negative (barriers) contributors to living with chronic pain after spinal cord injury (SCI).

DESIGN

Mixed-methods: (1) Qualitative (n=35): individual, semistructured, open-ended interviews identifying facilitator/barrier themes; (2) Quantitative (n=491): converting the most common themes into statements and quantifying agreement with these in an online survey to determine relative importance, underlying dimensions, and their associations with perceived difficulty in dealing with pain.

SETTING

University-based research setting and general community.

PARTICIPANTS

Volunteers (N=526) with SCI experiencing moderate to severe chronic pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interview guides, facilitator/barrier statements, and pain inventories.

RESULTS

Exploratory factor analyses reduced agreement ratings into 4 facilitators (information regarding pain and treatments, resilience, coping, medication use) and 5 barriers (poor health care communication, pain impact and limitations, poor communication about pain, difficult nature of pain, treatment concerns). Greater "pain impact and limitations," "difficult nature of pain," "poor communication from provider," lower "resilience," greater "medication use," and younger age predicted greater difficulty in dealing with pain (r=.75; F=69.02; P<.001).

CONCLUSIONS

This study revealed multiple facilitators and barriers to living with chronic pain after SCI. The principal barrier, "poor health care communication," indicated that consumers do not receive adequate information from their health care providers regarding pain. "Information regarding pain and treatments" had greater agreement scores and factor loadings than all other facilitators, indicating that most participants view provider-patient communication and educational efforts regarding pain and pain management as priorities and critical needs. Further initiatives in these areas are important for improving pain management post-SCI.