How to treat chronic pain in rheumatic and musculoskeletal diseases (RMDs) – A pharmacological review

IntroductionChronic pain is a common symptom of rheumatic diseases that impacts patients’ quality of life. While non-pharmacological approaches are often recommended as first-line treatments, pharmacological interventions are important for pain management. However, the effectiveness and safety of different pharmacological treatments for chronic pain in rheumatic diseases are unclear.MethodsThis review critically synthesizes the current evidence base to guide clinicians in selecting appropriate pharmacological treatments for their patients, considering the expected benefits and potential risks and side effects.ResultsFor osteoarthritis, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioids, and antidepressants are commonly used, with NSAIDs being the most recommended. In addition, topical agents, such as topical NSAIDs, are recommended for localized pain relief. For fibromyalgia, amitriptyline, serotonin and noradrenaline reuptake inhibitors (SNRIs), and gabapentinoids are commonly used, with SNRIs being the most recommended. For back pain, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioids are used only for acute of flare-up pain, whereas neuropathic pain drugs are only used for chronic radicular pain. For inflammatory rheumatic diseases, disease-modifying antirheumatic drugs (DMARDs) and biological agents are recommended to slow disease progression and manage symptoms.ConclusionWhile DMARDs and biological agents are recommended for inflammatory rheumatic diseases, pharmacological treatments for other rheumatic diseases only alleviate symptoms and do not provide a cure for the underlying condition. The use of pharmacological treatments should be based on the expected benefits and evaluation of side effects, with non-pharmacological modalities also being considered, especially for fibromyalgia.     

Calcitonina como agente analgésico: revisão dos mecanismos de ação e das aplicações clínicas

Background and objectivesCalcitonin is a polypeptide hormone regulating the metabolism calcium in the body. For many years calcitonin has been used to maintain and improve bone mineral density and to reduce the fracture rate. Many studies showed that calcitonin had analgesic role in several painful circumstances. This pain‐ameliorating effect is irrelevant to its osteoclastic inhibitory effect and mechanisms like altering Na+ channel and serotonin receptor expression or hypothesis including the endorphin‐mediated mechanism were used to explain this effect. In this study we performed a thorough review on the role of calcitonin as an analgesic agent in different scenarios and investigated the fact that calcitonin can be a feasible medication to relieve pain.MethodMany studies focused on the analgesic effect of calcitonin in several painful circumstances, including acute pains related to vertebral fractures, metastasis, migraine and reflex sympathetic dystrophy as well as neuropathic pains related to spinal injuries or diabetes, and phantom pain. Also, calcitonin was showed to be a useful additive to local anesthesia in the case of controlling postoperative pain or trigeminal neuralgia more effectively. However we faced some contradictory data for conditions like lumbar canal stenosis, complex regional pain syndrome, phantom pain and malignancies.ConclusionThis study showed that calcitonin could be helpful analgesic agent in different painful situations. Calcitonin can be considered an eligible treatment for acute pains related to vertebral fractures and a feasible alternative for the treatment of the acute and chronic neuropathic pains where other medications might fail.     

The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis

IntroductionRheumatoid arthritis (RA) is one of a number of inflammatory arthropathies resulting in foot pain and deformity. Patients with this disease may require surgical intervention as part of their management. Many of these patients are now taking biologic agents which pose several risks to patients in the perioperative phase. The surgical team therefore need to be aware of these associated complications and how to manage these cases.AimThis paper aims to review the current literature about perioperative needs (foot and ankle surgery) associated with patients with rheumatoid arthritis receiving biologic therapy.Main findingsThe majority of the literature discusses the perioperative complications associated with patients on anti-TNFα therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) have produced guidelines for the management of patients on anti-TNFα therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of post-operative infection need to be balanced against the risk of a post-operative disease flare. In essence, it is suggested anti-TNFα therapy is stopped 3–5 times the half-life of the drug whilst Tocilizumab is stopped 4 weeks prior to surgery.ConclusionGood communication is needed between the surgical team and the local Rheumatology department managing the patient’s disease in order to optimise perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.     

Opioids for chronic noncancer pain: recommendations based on clinical practice guidelines

ObjectiveThe need for major opioids in the treatment of chronic pain unrelated to cancer is increasing. We therefore appraised available clinical practice guidelines in order to identify recommendations for good practice in the use of these drugs.Material and methodsBy searching the main guideline repositories as well as resources provided by medical associations, we identified clinical practice guidelines on the use of major opioids published up to 2007. Fourteen of the 28 guidelines we found met the inclusion criteria. To appraise the guidelines we applied the criteria for scientific evidence of the AGREE collaboration (Appraisal of Guidelines Research and Evaluation). The AGREE instrument consists of 23 items organized in 6 areas for appraisal.ResultsOf the 14 guidelines appraised, 5 were judged to be of high quality. In each of the 5 selected guidelines, the relation between a recommendation and the evidence it was based on was stated explicitly; all 5 had overall quality scores over 60%. The recommendations drawn from these guidelines deal with 3 sequential moments in the use of opioids: start of treatment, maintenance therapy, and withdrawal of the drug.ConclusionThe use of opioids to treat chronic noncancer pain is controversial in terms of effectiveness, safety, and the possibility of addiction or abuse. The opioid should be indicated for the pain and prescribed with caution; each case should be assessed individually. Following the recommendations drawn from these guidelines will be important for achieving control of both pain and the accompanying symptoms. The use of major opioids to relieve chronic pain unrelated to cancer, and therefore to improve the quality of life of patients who experience this type of pain, is a legitimate treatment approach.     

Imaging for the diagnosis and follow-up of ankylosing spondylitis: development of recommendations for clinical practice based on published evidence and expert opinion

ObjectiveTo develop recommendations regarding imaging studies for the diagnosis and follow-up of patients with axial forms of ankylosing spondylitis (AS) seen in everyday practice.MethodsEvidence from the literature and expert opinion were used to develop the recommendations. Using the Delphi consensus procedure, a scientific committee selected five areas of interest, about which scientific evidence was sought by searching Medline and the databases maintained by the French Society for Rheumatology, European League against Rheumatism, and American College of Rheumatology. Based on this evidence, a panel of experienced rheumatologists drafted recommendations, using expert opinion if needed to supplement gaps in evidence. For each recommendation, the level of evidence and the extent of agreement among the experts were specified.ResultsThe five areas of interest dealt with the usefulness of imaging studies for the diagnosis, follow-up, prognostic evaluation, and assessment of treatment responses in patients with AS. The literature search retrieved 144 articles based on titles and abstracts. After elimination of articles that did not include an analysis of the radiological evaluation of AS, 73 articles were left for review. Eight recommendations were drafted then validated by having all panel participants vote during a final meeting.ConclusionEight recommendations about the use of imaging studies in patients with AS were developed. They can be expected to improve clinical practice uniformity and, in the longer term, to optimize the management of patients with AS.     

Beyond the hand and upper extremity: The role of hand therapists in care of people with rheumatic diseases

Study designInvited Clinical CommentaryBackgroundArthritis is one of the most frequently reported causes of disability in the United States and the prevalence is expected to increase in the coming decades. While many rheumatic diseases involve hand impairments, most are systemic and involve more than the musculoskeletal system. Functional and work disability are high and people would benefit from the services of occupational and physical therapists.Purpose of studyThis paper reviews concepts of self-management, and symptoms that contribute to limitations and restrictions to participation in daily life in people with rheumatic diseases and suggests roles for hand therapists beyond the immediate hand impairments.MethodsThe impact of selected rheumatic diseases on functional and work disability are reviewed along with strategies for symptom management and self-management. Upper extremity impairments of selected rheumatic diseases are also discussed.ResultsThe role for hand therapists in evaluating and addressing the complex needs of persons with rheumatic diseases, including less common diseases, is discussed. Outcome measures for fatigue, muscle involvement, ergonomics and computer use, and work disability are introduced. Finally, strategies for self-management and prevention of work and functional disability, along with symptom management for fatigue and pain are presented.ConclusionHand therapists can play a vital role in chronic rheumatic disease management to improve self-management and increase participation in meaningful activities. Patients, primary care and rheumatology providers need to be educated about the scope of services occupational and physical therapists provide beyond the hand impairments.     

2022 French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis,including psoriatic arthritis

ObjectiveUpdate the French Society for Rheumatology (SFR) recommendations on the everyday management of patients with spondyloarthritis, including psoriatic arthritis.MethodsFollowing standardized procedures, a systematic literature review was done by four supervised rheumatology residents based on questions defined by a task force of 16 attending rheumatologists. The findings were reviewed during three working meetings that culminated in each recommendation receiving a grade and the level of agreement among experts being determined.ResultsFive general principles and 15 recommendations were developed. They take into account pharmacological and non-pharmacological measures along with treatment methods based on the dominant phenotype present (axial, articular, enthesitis/dactylitis) and the extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis). NSAIDs are the first-line pharmacological treatment in the various presentations. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are not indicated in the axial and isolated entheseal forms. If the response to conventional treatment is not adequate, targeted therapies (biologics, synthetics) should be considered; the indications depend on the clinical phenotype and presence of extra-articular manifestations.ConclusionThis update incorporates recent data (published since the prior update in 2018) and the predominant clinical phenotype concept. It aims to help physicians with the everyday management of patients affected by spondyloarthritis, including psoriatic arthritis.     

An updated overview of clinical guidelines for chronic low back pain management in primary care

ObjectivesIn the past decade many countries around the world have produced clinical practice guidelines to assist practitioners in providing a care that is aligned with the best evidence. The aim of this study was to present and compare the most established evidence-based recommendations for the management of chronic nonspecific low back pain in primary care derived from current high-quality international guidelines.MethodsGuidelines published or updated since 2002 were selected by searching PubMed, CINAHL, EMBASE, guidelines databases, and the World Wide Web. The methodological quality of the guidelines was assessed by three authors independently, using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Guideline recommendations were synthesized into diagnostic and therapeutic approaches that were supported by strong, moderate or weak evidence.ResultsThirteen guidelines were included. In general, the quality was satisfactory. Guidelines had highest scores on clarity and presentation and scope and purpose domains, and lowest scores on applicability. There was a strong consensus among all the guidelines particularly regarding the use of diagnostic triage and the assessment of prognostic factors. Consistent therapeutic recommendations were information, exercise therapy, multidisciplinary treatment, and combined physical and psychological interventions.ConclusionCompared to previous assessments, the average quality of the guidelines dealing with chronic low back pain has improved. Furthermore, all guidelines are increasingly aligning in providing therapeutic recommendations that are clearly differentiated from those formulated for acute pain. However, there is still a need for improving quality and generating new evidence for this particular condition.     

Perfil do uso de drogas modificadoras de doença no Registro Brasileiro de Espondiloartrites

IntroductionFew studies have evaluated the profile of use of disease modifying drugs (DMD) in Brazilian patients with spondyloarthritis (SpA).MethodsA common research protocol was applied prospectively in 1505 patients classified as SpA by criteria of the European Spondyloarthropathies Study Group (ESSG), followed at 29 referral centers in Rheumatology in Brazil. Demographic and clinical variables were obtained and evaluated, by analyzing their correlation with the use of DMDs methotrexate (MTX) and sulfasalazine (SSZ).ResultsAt least one DMD was used by 73.6% of patients: MTX by 29.2% and SSZ by 21.7%, while 22.7% used both drugs. The use of MTX was significantly associated with peripheral involvement, and SSZ was associated with axial involvement, and the two drugs were more administered, separately or in combination, in the mixed involvement (p < 0.001). The use of a DMD was significantly associated with Caucasian ethnicity (MTX, p = 0.014), inflam- matory back pain (SSZ, p = 0.002), buttock pain (SSZ, p = 0.030), neck pain (MTX, p = 0.042), arthritis of the lower limbs (MTX, p < 0.001), arthritis of the upper limbs (MTX, p < 0.001), enthesitis (p = 0.007), dactylitis (MTX, p < 0.001), inflammatory bowel disease (SSZ, p < 0.001) and nail involvement (MTX, p < 0.001).ConclusionThe use of at least one DMD was reported by more than 70% of patients in a large cohort of Brazilian patients with SpA, with MTX use more associated with peripheral involvement and the use of SSZ more associated with axial involvement.     

Pharmacotherapy (excluding biotherapies) for ankylosing spondylitis: development of recommendations for clinical practice based on published evidence and expert opinion

ObjectivesTo develop recommendations about pharmacotherapy (excluding biotherapeutic agents) in patients with axial forms of ankylosing spondylitis (AS) seen in everyday clinical practice.MethodsThe recommendations were based on evidence from the literature. First, a scientific committee used a Delphi procedure to select five focal points about which recommendations were needed. Then, a literature task force looked for relevant publications in the following: Cochrane, PubMed, and Ovid databases; and abstracts from the French Society for Rheumatology, European League against Rheumatism, and American College of Rheumatology. Based on the data in these publications, recommendations were drafted then validated by a group of experts. The strength of each recommendation was determined, as well as the extent of agreement among the experts.ResultsThe four focal points were the best strategy for using nonsteroidal anti-inflammatory drugs, role for systemic glucocorticoid therapy, role for glucocorticoid injections into the sacroiliac joints and entheses, and role for slow-acting drugs (e.g., methotrexate, sulfasalazine, leflunomide, thalidomide, and pamidronate). Of the 661 promising publications identified by the literature search, 173 were found to be relevant. The evidence in these 173 papers was reported to experts during interactive workshops. At the end of the workshops, the experts drafted recommendations, which were then validated by having all panel participants vote during a final meeting. There were seven recommendations, whose strength ranged from A to D.ConclusionSeven recommendations about pharmacotherapy in patients with AS were developed. They can be expected to improve clinical practice uniformity and, in the longer term, to optimize the management of patients with AS in France.     

Diabetic neuropathic pain:Physiopathology and treatment

Diabetic neuropathy is a common complication of both type 1 and type 2 diabetes,which affects over 90% of the diabetic patients.Although pain is one of the main symptoms of diabetic neuropathy,its pathophysiological mechanisms are not yet fully known.It is widely accepted that the toxic effects of hyperglycemia play an important role in the development of this complication,but several other hypotheses have been postulated.The management of diabetic neuropathic pain consists basically in excluding other causes of painful peripheral neuropathy,improving glycemic control as a prophylactic therapy and using medications to alleviate pain.First line drugs for pain relief include anticonvulsants,such as pregabalin and gabapentin and antidepressants,especial y those that act to inhibit the reuptake of serotonin and noradrenaline.In addition,there is experimental and clinical evidence that opioids can be helpful in pain control,mainly if associated with first line drugs.Other agents,including for topical application,such as capsaicin cream and lidocaine patches,have also been proposed to be useful as adjuvants in the control of diabetic neuropathic pain,but the clinical evidence is insufficient to support their use.In conclusion,a better understanding of the mechanisms underlying diabetic neuropathic pain will contribute to the search of new therapies,but also to the improvement of the guidelines to optimize pain control with the drugs currently available.     

Long term clinical outcome of peripheral nerve stimulation in patients with chronic peripheral neuropathic pain

BackgroundChronic neuropathic pain after injury to a peripheral nerve is known to be resistant to treatment. Peripheral nerve stimulation is one of the possible treatment options, which is, however, not performed frequently. In recent years we have witnessed a renewed interest for PNS. The aim of the present study was to evaluate the long-term clinical efficacy of PNS in a group of patients with peripheral neuropathic pain treated with PNS since the 1980s.MethodsOf an original series of 11 patients, 5 patients could be invited for clinical examination, detailed assessment of clinical pain and QST examination. The assessments were done both during habitual use of PNS and with the stimulator off.ResultsAverage pain intensity and pain unpleasantness ratings as assessed with visual analog and verbal rating scales showed significant beneficial effects of PNS. Quality of life measures (sleep and daily functioning) also showed positive effects. Quantitative Sensory Testing results did not show significant differences in cold pain and heat pain thresholds between the “ON” and “OFF” conditions.ConclusionIn selected patients with peripheral neuropathic pain PNS remains effective even after more than 20 years.     

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication

BackgroundThe guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society.MethodsThe JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the “Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014”, which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.ResultsThe committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature.ConclusionsThe guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.     

Efficacy of spinal cord stimulators in treating peripheral neuropathy: a case series

IntroductionPeripheral neuropathy is a common cause of pain, and it is increasing in prevalence. Peripheral neuropathic pain is very hard to treat and can be resistant to multiple pain management modalities. Our series aimed at testing the efficacy of spinal cord stimulators (SCSs) in treating resistant painful peripheral neuropathy.Case PresentationsCase 1: A 79-year-old man presented to our clinic with long-standing history of painful peripheral diabetic neuropathy resistant to conservative management. After failure of all possible modalities, we offered the patient an SCS trial that was very successful, and we proceeded with the permanent implant that continued to help with his pain and allowed the patient to wean down his medications.Case 2: A 60-year-old man presented with chronic peripheral neuropathy secondary to HIV, patient failed all conservative and procedural management. Patient then had an SCS trial that relieved his pain significantly. Unfortunately, we did not proceed with the implant due to deterioration of the patient general health.Case 3: A 39-year-old woman presented with painful peripheral neuropathy secondary to chemotherapy for breast cancer. After failure of medication management and procedures, patient had a SCS trial that improved her pain and we then proceeded with performing the permanent implant that controlled her pain.ConclusionWe presented 3 cases with chronic painful peripheral neuropathy secondary to HIV, diabetes mellitus, and chemotherapy that was resistant to conservative pain management and procedures that was successfully treated with neurostimulation.     

Proprioception: How is it affected by shoulder pain? A systematic review

IntroductionProprioception encompasses the submodalities of joint position sense (JPS), kinesthesia, sense of force, and velocity. Owing to the vast mobility of the shoulder, it heavily relies on an intact sense of proprioception. Moreover, shoulder injuries are associated with a decreased sense of proprioception. What remains unclear is how shoulder proprioception is affected by pain and competing nociceptive senses.Purpose of the StudyTo summarize the literature evaluating the relationship between pain and shoulder proprioception.MethodsA literature review was conducted from inception until 22 October 2018, using electronic databases (PubMed, Web of Science, Scopus, EBSCO, CINAHL, and Embase). Retrieved citations were screened for eligibility, and methodological quality was assessed using the Newcastle-Ottawa Scale (NOS).ResultsEleven studies were included (n = 447 participants with shoulder pain, n = 20 with experimentally induced pain [EIP]/n = 600 painful shoulders and n = 20 [EIP]). The mean methodological quality of the studies was good (76%). Five studies investigated active JPS, four investigated passive JPS, six investigated kinesthesia, sense of force was measured in one study, and no study investigated sense of velocity. There is moderate evidence for impaired kinesthesia and low evidence for reduced sense of force among painful shoulders. Conflicting evidence is seen for the other proprioceptive submodalities.ConclusionThe overall impact of pain on shoulder JPS remains unclear, while moderate evidence for an affected sense of kinesthesia is possible. There is low evidence for an impaired sense of force among painful shoulders. Standardization between studies is lacking, limiting the range of our conclusions. Further investigation is required into well-controlled and pain-induced studies to better understand the influence of pain on shoulder proprioception.     

Dietary recommendations of the French Society for Rheumatology for patients with chronic inflammatory rheumatic diseases

This article presents the 1st set of dietary recommendations of the French Society for Rheumatology for patients suffering from chronic inflammatory rheumatic diseases (IRD) made by a working group consisting of 12 rheumatology experts, 3 physician nutrition specialists, 1 internal medicine specialist, 1 registered dietician and 3 representatives from patient associations. This group relied on a systematic literature review and on expert opinions, while taking into consideration not only the joint effects of diet in IRD but also the extra-articular ones. Eight general principles and nine recommendations were established. The general principles emphasize that nutritional advice is not a substitute for pharmacological treatment of IRD and that it is an integral part of the patients’ overall care, which could help the patient actively participate in their care. The recommendations propose supporting weight loss in subjects who are overweight or obese, a Mediterranean-type diet and supplementation in polyunsaturated fatty acids, mainly omega-3. Conversely, gluten-free diets (in the absence of celiac disease), vegetarian/vegan diets, fasting and elimination of dairy products should not be proposed. Supplementation with vitamins or trace elements is not indicated for controlling chronic IRD activity, while the use of probiotics or spices is not recommended given the limited or disparate data.     

The role of radioisotopes for the palliation of bone pain from bone metastases

Bone metastasis occurs as a result of a complex pathophysiologic process between host and tumor cells leading to cellular invasion, migration adhesion, and stimulation of osteoclastic and osteoblastic activity. Several sequences occur as a result of osseous metastases and resulting bone pain can lead to significant debilitation. Pain associated with osseous metastasis is thought to be distinct from neuropathic or inflammatory pain. Several mechanisms, such as invasion of tumor cells, spinal cord astrogliosis, and sensitization of nervous system, have been postulated to cause pain. Pharmaceutical therapy of bone pain includes nonsteroidal analgesics and opiates. These drugs are associated with side effects, and tolerance to these agents necessitates treatment with other modalities. Bisphosphonates act by inhibiting osteoclast-mediated resorption and have been increasingly used in treatment of painful bone metastasis. While external beam radiation therapy remains the mainstay of pain palliation of solitary lesions, bone-seeking radiopharmaceuticals have entered the therapeutic armamentarium for the treatment of multiple painful osseous lesions. ^32p has been used for over 3 decades in the treatment of multiple osseous metastases. The myelosuppression caused by this agent has led to the development of other bone-seeking radiopharmaceuticals, including ^89SrCl, and ^153Sm-ethylenediaminetetramethylene phosphonic acid （^153Sm-EDTMP）. ^89Sr is a bone-seeking radionuclide, whereas ^153Sm-EDTMP is a bone-seeking tetraphosphonate; both have been approved by the Food and Drug Administration for the treatment of painful osseous metastases. While both agents have been shown to have efficacy in the treatment of painful osseous metastases from prostate cancer, they may also have utility in the treatment of painful osseous metastases from breast cancer and perhaps from non-small cell lung cancer. This article illustrates the salient features of these radiopharmaceuticals, including the approved dose, method of administration, and indications for use.     

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).

Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.

Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.

Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.