Is acupuncture effective in treating chronic pain after spinal cord injury?

OBJECTIVES: To evaluate the efficacy of acupuncture as a treatment for chronic pain and secondary symptoms after spinal cord injury (SCI) and to identify disease-specific variables associated with response to treatment. DESIGN: A within-subjects design consisting of a 7(1/2)-week no-acupuncture baseline period followed by a 7(1/2)-week treatment period and a follow-up assessment 3 months posttreatment. SETTING: Medical rehabilitation research center. PARTICIPANTS: Twenty-two people with SCI who experienced moderate to severe pain of at least 6 months' duration. INTERVENTION: A course of 15 acupuncture treatments was administered over a 7(1/2)-week period. MAIN OUTCOME MEASURES: Numeric Rating Scale of pain intensity; ratings of interference with activity, individualized symptom rating, Center for Epidemiologic Studies-Depression Scale; Speilberger State Trait Anxiety Inventory, and General Well-Being Schedule. RESULTS: Ten patients (46%) showed improvement in pain intensity and pain sequelae after treatment. However, 6 patients (27%) reported an increase in pain that was still present 3 months after treatment. CONCLUSIONS: About 50% of the study sample reported substantial pain relief after acupuncture treatment, suggesting that acupuncture may provide pain relief for at least a subgroup of individuals with SCI. Future research is needed to determine what part of this effect is because of acupuncture versus nonspecific effects such as placebo effects and regression to the mean.     

Chronic neuropathic pain of spinal cord injury: What is the effectiveness of psychocomportemental management?

ObjectivesTo determine the efficacy of treating neuropathic pain in spinal cord injury (SCI) patients by psychological, cognitive or behavioral therapies and suggest recommendations for clinical practices.Material and methodThe methodology used, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic review of the literature, the gathering of information regarding current clinical practices and a validation by a multidisciplinary panel of experts.ResultsDue to the dearth of literature on the subject only one study is found, evaluating the efficacy of these therapies on neuropathic pain but not on the chronic neuropathic pain of SCI patients. The results show a greater efficacy on the associated symptoms: anxiety and depression level, sleep disorders, rather than the pain itself.ConclusionThere is no scientific evidence for validating this type of pain management care. However, the high level of evidence of the articles studying the efficacy of these therapies in patients with chronic pain suggest that it could be applied to SCI patients. These techniques must be developed in France and further studies should be conducted on SCI patients affected by neuropathic pain.     

What are the risk factors of occurence and chronicity of neuropathic pain in spinal cord injury patients?

ObjectiveAnalyze the epidemiological data on neuropathic pain in spinal cord injury patients and determine the risk factors for its occurrence and chronicity.MethodReview and analysis of the literature.ResultsEpidemiological data report that 40% of spinal cord injury (SCI) patients suffer from neuropathic pain and 40% of these patients report an intense neuropathic pain. Some factors do not seem to be predictive for the onset of neuropathic pain: the level of injury, complete or incomplete injury, the existence of an initial surgery, sex. However, old age at the time of injury, bullet injury as the cause of trauma, early onset of pain in the weeks following the injury, their initial nature, intensity and continuous pain, as well as associated symptoms all appear to be negative prognostic factors.ConclusionNeuropathic pain in SCI patients is a major issue, its determining factors still need to be evaluated properly by refining the epidemiological data.     

The chronic neuropathic pain of spinal cord injury: Which efficiency of neuropathics stimulations?

ObjectiveDetermine the efficacy of spinal cord stimulation (SCS) for treating neuropathic pain in spinal cord injury (SCI) patients.Material and methodsWe proceeded with a data analysis of the French and English medical literature with the following keywords: chronic neuropathic pain, spinal cord stimulation. The quality of every selected article was analyzed according to criteria established by the French National Health Authority (HAS).ResultsEighty-three articles were read, 27 of them report clinical studies on SCS on at least one SCI patient. No article had a level of proof lower than 4.ConclusionThere is no significant level of proof to recommend the use of this technique in this indication. Conducting further studies, either physiological or clinical, could help to promote this technique with very minor adverse effects in an indication which, to this day, has no gold standard.     

What is the efficacy of physical therapeutics for treating neuropathic pain in spinal cord injury patients?

ObjectiveEvaluate the place and level of proof of physical therapeutics for treating neuropathic pain in spinal cord injury (SCI) patients.MethodLiterature review from three databases: PubMed, Embase, Pascal. The following keywords were selected: chronic neuropathic pain/non-pharmacological treatment; transcutaneous electrical nerve stimulation, physiotherapy, acupuncture, physical therapy, transcranial magnetic stimulation, heat therapy, ice therapy, cold therapy, massage, ultrasound, alternative treatment, complementary treatment, occupational therapy. The articles were analyzed using the double-reading mode.ResultsThree techniques emerge from the literature: magnetic or electrical transcranial stimulation, transcutaneous electrical nerve stimulation and acupuncture. Even though the first method is not easily accessible on a daily basis it is the one that yields the most promising results validated by Grade B studies. Healthcare professionals remain faithful to pain-relieving transcutaneous neurostimulation for both segmental neuropathic pain and below-level central neuropathic pain. Acupuncture is advocated by Canadian teams and could offer some interesting options; however, to this day, it does not have the methodological support and framework required to validate its efficacy. All other physical therapies are used in a random way. Only below-level massages are advocated by the patients themselves.ConclusionTo this day, no study can validate the integration of physical therapy as part of the array of therapeutics used for treating neuropathic pain in SCI patients. In the future, it will require controlled and randomized therapeutic studies on homogenous groups of SCI patients, to control the various confusion factors.     

Chronic pain after spinal cord injury: what characteristics make some pains more disturbing than others?

Different types of pain are often present in the same individual with spinal cord injury (SCI). Relieving the most disturbing of these pains may substantially affect quality of life. Persons with SCI and chronic pain (n = 194) completed a structured interview that detailed the characteristics of each pain they experienced. Pairwise analyses revealed that the following characteristics were more common among the most disturbing pains: "sharp"; "stabbing"; located at the level of injury; frequently aggravated; and having high intensity, unpleasantness, constancy, interference, and neuropathic pain-like features. A conditional logistic regression analysis showed that the combination of "sharp" and high pain intensity, interference, aggravation, and constancy significantly predicted the most disturbing pain (p < 0.001). This study suggests that, in addition to pain intensity, factors such as interference, quality, aggravation, and constancy of pain are important to consider when one evaluates SCI-related pain, since these symptoms may indicate pains that are particularly disturbing to an individual with SCI.     

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

Purpose: The present purpose was to explore patients’ and involved physicians’ needs and requests for improving their management of neuropathic pain following spinal cord injury (SCI). Methods: Sixteen patients with SCI and neuropathic pain, and nine physicians, were interviewed in focus-groups or individual interviews. An emergent design was used and the interviews and analyses were carried out in parallel, making it possible to use and deepen new emerging knowledge. The interviews were transcribed verbatim and processed according to content analysis. Results: A final model with four themes described the results. Three themes covered the current situation: limitations in structure, lack of knowledge and competence, and frustrations. A fourth theme, needs and requests, described suggestions by patients and physicians for future improvements. Suggestions included increased participation, increased patient involvement in the pain rehabilitation process, support in the process of learning to live with pain, implementation of multi-modal pain rehabilitation, and the use of complementary treatments for neuropathic pain. Conclusion: Neuropathic pain following SCI needs to be assessed and treated using a structured, inter-disciplinary, multi-modal rehabilitation approach involving patients in planning and decision-making.

• Implications for Rehabilitation

• For improving SCI neuropathic pain management, there is a great need for individually-tailored management, planned in a dialogue on equal terms between health care and the patient.

• Patients desire continuity and regularity and the possibility of receiving complementary treatments for SCI neuropathic pain.

• Access to structured pain rehabilitation is needed.

• Support and tools need to be provided in the learning-to-live with pain process.

     

Chronic neuropathic pain management in spinal cord injury patients. What is the efficacy of pharmacological treatments with a general mode of administration? (oral,transdermal, intravenous)

IntroductionThe pharmacological treatment of patients with spinal cord injury (SCI) pain remains challenging despite new available drugs. Such treatment should always be viewed in the context of global pain management in these patients. To date few clinical trials have been specifically devoted to this topic, and the implementation of treatments is generally based on results obtained in peripheral neuropathic pain. The aim of this review is to present evidence for efficacy and tolerability of pharmacological treatments in SCI pain and propose therapeutic recommendations.Material and methodsThe methodology follows the guidelines of the French Society of Physical Medicine and Rehabilitation (SOFMER). It includes a systematic review of the litterature which is performed by two independent experts. The selected studies are analysed and classified into four levels of evidence (1 to 4) and three grades of recommendations are proposed (A, B, C). The review is further validated by a reading committee.ResultsThe efficacy of pregabalin has been confirmed in neuropathic pain associated with SCI (grade A). Gabapentin has a lower level of evidence in SCI pain (grade B) but a grade A level of evidence for efficacy in peripheral neuropathic pain. Both drugs can be proposed as first line therapy and are safe to use. Tricyclic antidepressants (TCAs) can also be proposed first line (grade B for SCI pain associated with depression, grade A for other neuropathic pain conditions), especially in patients with comorbid depressive symptoms. Tramadol can be proposed alone or in combination with antiepileptic drugs if the pain has a predominant non-neuropathic component. If these treatments fail, strong opioids can be proposed as second/third line (grade B in SCI, grade A in other types of neuropathic pain). Lamotrigine may also be proposed at this stage, particularly in patients with incomplete SCI associated with allodynia (grade B). In refractory central pain, cannabinoids may be proposed on the basis of positive results in other central pain conditions (e.g. multiple sclerosis). Intravenous ketamine and lidocaine can only be proposed in specialized centers. Drug combinations may be envisaged in case of partial response to first or second line therapy.ConclusionsVery few pharmacological studies have dealt specifically with neuropathic pain related to SCI. Large scale studies and trials comparing several active drugs are warranted in SCI pain.     

Do communities matter after rehabilitation? The effect of socioeconomic and urban stratification on well-being after spinal cord injury

Botticello AL, Chen Y, Cao Y, Tulsky DS. Do communities matter after rehabilitation? The effect of socioeconomic and urban stratification on well-being after spinal cord injury.

Objective

To assess the influence of community-level socioeconomic status (SES) and urban composition on well-being after spinal cord injury (SCI) rehabilitation.

Design

Retrospective analysis of cross-sectional survey data.

Setting

Two participating centers in the SCI Model Systems (SCIMS) program.

Participants

Persons (N=1454) with traumatic SCI from New Jersey and Alabama enrolled in the SCIMS database in 2000 to 2009.

Intervention

Not applicable.

Main Outcome Measures

Dichotomous measures of perceived health (ill vs good health), life satisfaction (dissatisfied vs satisfied), and depressive symptoms (presence of a syndrome vs not) to assess well-being.

Results

Multilevel logistic regression was used to model community effects on each indicator of well-being. The likelihood of ill health and dissatisfaction with life in people with SCI, but not depressive symptoms, varied across communities. Community SES was related inversely to the odds of reporting ill health. However, the odds for dissatisfaction were higher in persons with SCI living in high SES and urban communities. Associations between community predictors and dissatisfaction with life were sustained after controlling for individual differences in injury severity, SES, and demographics, whereas individual SES was a stronger predictor of ill health than community SES.

Conclusion

This research suggests that community stratification influences the likelihood for diminished well-being for persons with SCI after rehabilitation. Understanding the contribution of communities in long-term outcomes after SCI rehabilitation is needed to inform future interventions aimed at preventing disability in this population.     

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

Purpose: To explore and obtain increased knowledge about (i) strategies and treatments used by individuals with neuropathic pain following spinal cord injury (SCI) for handling long-term pain, and (ii) their experience, needs and expectations of SCI neuropathic pain management. Methods: Qualitative methods with an emergent research design were used. Eighteen informants who suffered from long-term SCI neuropathic pain participated. Data were collected with diaries and thematized research interviews. Content analysis and constant comparison according to grounded theory were used for the analyses. Results: A model with four categories emerged: “Pain is my main problem” explained the impact of pain in the informants’ everyday life; “Drugs – the health care solution” described the informants’ experience of pain management; “The gap in my meeting with health care” described the discrepancy between what the informants wanted and what health care could offer. “But…this works for me” described treatments and strategies, which the informants found helpful for pain control and pain relief. Conclusion: Neuropathic pain, one of the major problems following SCI, is difficult to treat successfully. To improve treatment outcome, health care needs to listen to, respond to and respect the patient’s knowledge, experience and wishes. Future research needs to address treatments that patients find effective.

Implications for Rehabilitation

• Patients’ experiences, knowledge and preferences need to be taken into account when designing pain management.

• Complementary treatments (non-pharmacological) ought to be an important part of successful neuropathic pain management.

     

Do post-traumatic stress symptoms predict reactions of adaptation to disability after a sudden-onset spinal cord injury?

Based on the perspective that post-traumatic stress disorder (PTSD) reflects a reaction of adaptation to trauma, the goal of this research was to examine the ability of PTSD symptom clusters (re-experiencing, avoidance, and hyperarousal) to predict eight reactions of adaptation to disability (shock, anxiety, denial, depression, internalized anger, externalized hostility, acknowledgment, and adjustment) among individuals with non-congenital spinal cord injuries. Individuals (all of whom attended either a specialized civilian or a veteran spinal cord injury clinic in Texas) completed two self-report questionnaires--the Reactions to Impairment and Disability Inventory (RIDI) and the Purdue Posttraumatic Stress Disorder Scale Revised (PPTSD-R). According to the statistical fit indices, five of the fit indices suggested that the revised model was a good fit to the data, whereas one fit index and the chi/df ratio indicated that the revised model fit the data poorly. The model provided information on the ability of PTSD clusters to predict reactions of adaptation, which suggested a specific pattern of vacillation of post-traumatic responses during the process of adaptation. These findings need replication before proposing interventions for post-traumatic stress responses after the onset of a spinal cord injury.     

Return to work in the context of everyday life 7–11 years after spinal cord injury – a follow-up study

Abstract

Purpose: The aim of this follow-up study was to explore experiences of return to work in the context of everyday life among adults 7–11 years after spinal cord injury (SCI).

Methods: This study used in-depth interviews and observations in a qualitative design with eight persons who had previously been interviewed in 2008. A narrative approach was used during data gathering and analysis.

Results: Return to work was experienced as something constantly needing to be negotiated in the context of everyday life. Several years after SCI expectations for work and perceptions of possibilities for meaningful work had changed. Five main themes were identified through the analysis, (1) negotiating the possibilities of working, (2) hope for future work tempered with concern, (3) education as a possible path to employment, (4) paths toward return to work in light of unmet support, and (5) unpaid occupations grounded in interest and competence.

Conclusions: Persons who have no higher education or lack viable employment to return to after SCI seem to be vulnerable in return to work. Early and timely interventions tailored to the person’s interests and competencies, in which the rehabilitation team has a distinct coordinating role, are thus critical in return to work.

• Implications for Rehabilitation

• Tensions between hope and expectations for work and unmet needs of support can lead to barriers in return to work, particularly for those who have no higher education or lack employment to return to after spinal cord injury.

• Rehabilitation after spinal cord injury can benefit from focus on how the balance of work fits into routines in the context of everyday life.

• Early and timely interventions integrating the person’s interests and competencies in return to work after spinal cord injury in combination with having a health care provider who has a distinct coordinating role are critical.

     

Chronic neuropathic pain in spinal cord injury patients: What is the impact of social and environmental factors on care management?

ObjectiveIn order to refine therapeutic strategies for spinal cord injury (SCI) patients with chronic neuropathic pain, it appears essential to assess the impact of socioenvironmental factors on the onset of pain or its chronic nature. The aim of this article is to answer the following question regarding these factors: is there any evidence that managing these social and environmental factors could have a positive impact on the treatment of chronic neuropathic pain in SCI patients?MethodologyThe English keywords were: Chronic neuropathic pain in spinal cord injury/human/adult and rehabilitation; functional independence; community integration; family support; employment; social environment; social support; life satisfaction; quality of life.ResultsThirty-four articles were selected, the data extracted from the literature highlighted several socioenvironmental factors that could have a potential impact on the onset of neuropathic pain in spinal cord injury patients.ConclusionIt was impossible to directly answer this question based on the literature review only. Nonetheless, some socioenvironmental factors can be considered as potential triggering factors for the onset of chronic pain in spinal cord injury patients, i.e. a low degree of independence (C), low socioeconomic status (B), unemployment (B), and family and friends with a “negative attitude” (C).     

A role for peripheral afferents in the pathophysiology and treatment of at-level neuropathic pain in spinal cord injury? A case report

At-level neuropathic pain is a frequent symptom following spinal cord injury, but the underlying pathophysiology is not completely understood. We report a patient suffering from treatment-resistant at-level pain characterized by ongoing pain and mechanical allodynia for three years after an incomplete spinal lesion. Quantitative sensory testing revealed severe thermosensory deficits in the neuropathic pain area. However, topical application of capsaicin in the neuropathic pain area induced a burning pain sensation, a marked decrease in heat pain threshold and an increase in mechanical allodynia. Treatment with topical lidocaine patches (5%) led to considerable pain relief. These results indicate a functional connection between peripheral, spinal and supraspinal nociceptive pathways and that peripheral afferents may contribute to at-level neuropathic pain after spinal cord injury in this patient. Lesioned peripheral afferents in combination with central neuronal hyperexcitability are discussed as a likely underlying pain mechanism.     

Chronic neuropathic pain in patients with spinal cord injury. What is the efficacy of regional interventions? Sympathetic blocks,nerve blocks and intrathecal drugs

ObjectiveTo elaborate recommendations regarding neuropathic pain management in spinal cord injury patients. The goal was to evaluate the efficacy of local anesthetic therapeutics including intrathecal or epidural treatments, sympathetic and nerve blocks.MethodThe methodology, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic revue of the literature, the gathering of information regarding current clinical practice and a validation by a multidisciplinary panel of experts.ResultsThe results of the literature review do not validate the efficacy of clonidine, baclofen, morphine or lidocaine administered via intrathecal (IT) drug delivery or epidural injections on neuropathic pain in spinal cord injury patients. One reason could be the methodological limitations of the studies. Another reason could be that in most cases the evaluation is done after one single dose injection, thus preventing the authors from assessing the efficacy of the treatments on the long-term. Various clinical practices experiences lead us into thinking that there is, in some cases, a real efficacy for IT baclofen delivery, but this still remains to be properly defined in terms of patients characteristics and type of neuropathic pain. Regarding anesthetic nerve root blocks and sympathetic blocs, no element is available to validate the efficacy of these techniques.ConclusionThere is not a sufficient level of proof to recommend using IT or epidural drug delivery for treating neuropathic pain. However, according to the clinical practices data reviewed, we can suggest to conduct further studies on the impact of IT baclofen delivery that seems to have a pain-relieving impact in some situations. It would be interesting to identify the subgroups of patients that could benefit from this treatment.     

How does spinal cord injury affect marital relationship? A story from both sides of the couple

Purpose: To explore the impact of spinal cord injury (SCI) upon the family and marital relationship in Hong Kong. Method: Semi-structured interviews were conducted on 66 persons with SCI and 40 spouses. Qualitative information on family and marital relationships, life satisfaction, social functioning and leisure activities was transcribed and analysed. Results and Conclusion: It was found that the impact of the SCI was manifested in different but interrelated aspects onto the individuals and their spouses. However, many of the problems were due to the lack of communication between them. Rehabilitation professionals should then treat the couple as a single unit in order to facilitate mutual understanding and get rid of any distorted perception.     

Postural control strategy after incomplete spinal cord injury: effect of sensory inputs on trunk–leg movement coordination

Stiff-Knee gait (SKG) after stroke is often accompanied by decreased knee flexion angle during the swing phase. The decreased knee flexion has been hypothesized to originate from excessive quadriceps activation. However, it is unclear whether hyperreflexia plays a role in this activation. The goal of this study was to establish the relationship between quadriceps hyperreflexia and knee flexion angle during walking in post-stroke SKG. The rectus femoris (RF) H-reflex was recorded in 10 participants with post-stroke SKG and 10 healthy controls during standing and walking at the pre-swing phase. In order to attribute the pathological neuromodulation to quadriceps muscle hyperreflexia and activation, healthy individuals voluntarily increased quadriceps activity using electromyographic (EMG) feedback during standing and pre-swing upon RF H-reflex elicitation. We observed a negative correlation (R = − 0.92, p = 0.001) between knee flexion angle and RF H-reflex amplitude in post-stroke SKG. In contrast, H-reflex amplitude in healthy individuals in presence (R = 0.47, p = 0.23) or absence (R = − 0.17, p = 0.46) of increased RF muscle activity was not correlated with knee flexion angle. We observed a body position-dependent RF H-reflex modulation between standing and walking in healthy individuals with voluntarily increased RF activity (d = 2.86, p = 0.007), but such modulation was absent post-stroke (d = 0.73, p = 0.296). RF reflex modulation is impaired in post-stroke SKG. The strong correlation between RF hyperreflexia and knee flexion angle indicates a possible regulatory role of spinal reflex excitability in post-stroke SKG. Interventions targeting quadriceps hyperreflexia could help elucidate the causal role of hyperreflexia on knee joint function in post-stroke SKG.