Cecilia Norrbrink

International Spinal Cord Injury Pain Classification: part I. Background and description

Study design:Discussion of issues and development of consensus.Objective:Present the background, purpose, development process, format and definitions of the International Spinal Cord Injury Pain (ISCIP) Classification.Methods:An international group of spinal cord injury (SCI) and pain experts deliberated over 2 days, and then via e-mail communication developed a consensus classification of pain after SCI. The classification was reviewed by members of several professional organizations and their feedback was incorporated. The classification then underwent validation by an international group of clinicians with minimal exposure to the classification, using case study vignettes. Based upon the results of this study, further revisions were made to the ISCIP Classification.Results:An overall structure and terminology has been developed and partially validated as a merger of and improvement on previously published SCI pain classifications, combined with basic definitions proposed by the International Association for the Study of Pain and pain characteristics described in published empiric studies of pain. The classification is designed to be comprehensive and to include pains that are directly related to the SCI pathology as well as pains that are common after SCI but are not necessarily mechanistically related to the SCI itself.Conclusions:The format and definitions presented should help experienced and non-experienced clinicians as well as clinical researchers classify pain after SCI.

Tramadol in Neuropathic Pain After Spinal Cord Injury A Randomized, Double-blind, Placebo-controlled Trial

ObjectivesTo assess the efficacy and safety of tramadol for relieving neuropathic pain after spinal cord injury (SCI). MethodsThirty-six patients with SCI and neuropathic pain were enrolled in a randomized, double-blind, placebo-controlled trial, and 35 patients were included in the intention-to-treat analysis based on all patients taking at least 1 dose of study medication. Of the intention-to-treat population, 23 were randomized to treatment with tramadol and 12 to placebo. Patients were given study medication for 4 weeks, starting with 3 times 50 mg tramadol daily or 3 times 1 tablet of placebo. ResultsAt evaluation, 4 weeks after the treatment initiation, ratings of pain intensity were lower in those randomized to tramadol compared with those on placebo. Pain severity scores on the Multidimensional Pain Inventory had also decreased in patients on tramadol. No between-group differences in pain affect were observed. Adverse events were substantial and caused 43% of those on tramadol and 17% on placebo to withdraw from the study. DiscussionTramadol might be tried for neuropathic pain after SCI after the use of gabapentin/pregabalin, and tricyclic antidepressants have been found to be insufficient. Titration should be slow and individual, to minimize the risk of adverse events.

Screening tools for neuropathic pain: can they be of use in individuals with spinal cord injury?

&NA; Pain of both neuropathic and nociceptive aetiology is common after spinal cord injury (SCI), and classifying pain is sometimes a challenge. The objective of this study was to test the usefulness of the Swedish version of the screening tools Douleur Neuropathique 4 questions (DN4), the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), the Neuropathic Pain Questionnaire (NPQ), and the painDETECT Questionnaire (PD‐Q) in individuals with SCI and pain. A further objective was to define pain descriptors able to discriminate neuropathic pain from nonneuropathic pain. Forty individuals with SCI ⩾1 year and pain ⩾6 months were examined by a specialised physician and assessed twice using the 4 screening tools. The analysis included tests of reliability (test–retest) and validity (calculation of sensitivity, specificity, and overall agreement), an explorative analysis of the cutoff scores and regression analysis for identifying predictors of diagnostic accuracy. Our results indicate that reliability was good to very good for 3 of the screening tools, DN4, LANSS, and NPQ with a Cohen’s kappa coefficient between 0.70 and 1.00. DN4 showed the highest sensitivity (93%), followed by PD‐Q (68%), NPQ (50%), and LANSS (36%). LANSS and NPQ demonstrated the highest specificity (100%), followed by PD‐Q (83%) and DN4 (75%). Diagnostic accuracy for the tools was for DN4 88%, PD‐Q 78%, NPQ 65%, and LANSS 55%. A final model showed that 3 items, hypoesthesia to touch, burning pain, and numbness, could discriminate pain in this cohort of individuals with SCI with a high goodness of fit. This study indicates that the Douleur Neuropathique 4 (Swedish version) has high reliability and validity and can be used as screening tool for neuropathic pain in spinal cord injury.

International Spinal Cord Injury Pain (ISCIP) Classification: Part 2. Initial validation using vignettes.

Study design:International validation study using self-administered surveys.Objectives:To investigate the utility and reliability of the International Spinal Cord Injury Pain (ISCIP) Classification as used by clinicians.Methods:Seventy-five clinical vignettes (case histories) were prepared by the members of the ISCIP Classification group and assigned to a category by consensus. Vignettes were incorporated into an Internet survey distributed to clinicians. Clinicians were asked, for each vignette, to decide on the number of pain components present and to classify each using the ISCIP Classification.Results:The average respondent had 86% of the questions on the number of pain components correct. The overall correctness in determining whether pain was nociceptive was 79%, whereas the correctness in determining whether pain was neuropathic was 77%. Correctness in determining if pain was musculoskeletal was 84%, whereas for visceral pain, neuropathic at-level spinal cord injury (SCI) and below-level SCI pain it was 85%, 57% and 73%, respectively. Using strict criteria, the overall correctness in determining pain type was 68% (versus an expected 95%), but with maximally relaxed criteria, it increased to 85%.Conclusions:The reliability of use of the ISCIP Classification by clinicians (who received minimal training in its use) using a clinical vignette approach is moderate. Some subtypes of pain proved challenging to classify. The ISCIP should be tested for reliability by applying it to real persons with pain after SCI. Based on the results of this validation process, the instructions accompanying the ISCIP Classification for classifying subtypes of pain have been clarified.

PAIN RELIEF IN WOMEN WITH FIBROMYALGIA: A CROSS-OVER STUDY OF SUPERFICIAL WARMTH STIMULATION AND TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION

OBJECTIVE To compare the effects of portable superficial warmth with transcutaneous electrical nerve stimulation on pain in patients with fibromyalgia. METHODS The study had a randomized cross-over design. A total of 32 patients with fibromyalgia were randomly assigned to 2 groups. After instruction, the patients treated themselves using a portable device providing superficial warmth (42 degrees C) or a transcutaneous electrical nerve stimulation apparatus. After 3 weeks the patients switched therapy. The patients rated pain intensity on a 0-100 numerical rating scale before and after each treatment. After 6 weeks, patients were questioned concerning therapy preference. RESULTS There was no difference in level of pain relief when comparing the 2 treatment modes. Median pain intensity in patients using warmth therapy decreased from 77.5 on the numerical rating scale before treatment to 62.5 after treatment and in patients using transcutaneous electrical nerve stimulation from 80 to 62.5. Ten patients reported a reduction of 20 units or more on the numerical rating scale after warmth therapy, as did 10 after transcutaneous electrical nerve stimulation. Seventeen of 32 patients preferred warmth therapy and 10 preferred transcutaneous electrical nerve stimulation. CONCLUSION Sensory stimulation with superficial warmth or transcutaneous electrical nerve stimulation yielded comparable temporary pain reduction in patients with fibromyalgia. Both procedures are self-administered, safe and in-expensive.

Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study

Objective The study sought to explore the possibility of using acupuncture and massage therapy for relieving neuropathic pain following spinal cord injury (SCI). Design 30 individuals with SCI and neuropathic pain were assigned to treatment of either massage or acupuncture, with 15 individuals in each group. Both groups received treatment twice weekly for 6 weeks. Treatments were evaluated at the end of treatment and 2 months later (follow-up). Results Data were analysed on an intention-to-treat basis. Within the groups, ratings of present pain, general pain, pain unpleasantness and coping improved significantly at the end of treatment after acupuncture compared to baseline values, and following massage therapy ratings of pain interference on the Multidimensional Pain Inventory improved. At follow-up no significant improvements were seen. Between-group differences were seen regarding ratings of worst pain intensity at the end of treatment, and regarding pain unpleasantness and coping with pain at follow-up, both in favour of acupuncture. At the end of treatment, eight of the 15 individuals receiving acupuncture and nine receiving massage reported an improvement on the Patient Global Impression of Change Scale, and at follow-up six patients in the acupuncture group and one patient in the massage group still reported a favourable effect from the treatment. Few side effects were reported and neither dropout from the study did this due to adverse events. Conclusion Neuropathic pain following SCI is often only partially responsive to most interventions. Results from this study indicate, however, that both acupuncture and massage therapy may relieve SCI neuropathic pain. For this reason, larger randomised controlled trials are warranted for assessing the long-term effects of these treatments.

Spasticity and bone density after a spinal cord injury.

STUDY DESIGN Descriptive, cross-sectional study. OBJECTIVE To assess the relationship between spasticity and bone mineral density in the lower extremities in individuals with a motor complete spinal cord injury. METHODS Eighteen individuals, matched for time since injury, gender, and age, were included in the study. Nine men had severe spasticity, and 9 men had spasticity that was either mild or not present. Comparisons regarding bone mineral density were made using dual energy X-ray absorptiometry. Regions of interest measured were total leg, pelvis, femoral neck and total hip. Between-group differences regarding fat and lean tissue were analysed. RESULTS Background data, such as weight, height, standing and exercising habits, smoking and alcohol use, were similar in both groups. There was no difference between the groups regarding bone mineral density. All of the participants presented with osteoporosis or osteopaenia values at the hips. Participants with severe spasticity had larger muscle volume than those with none or mild spasticity. No correlations between bone mineral density and body composition with age or time since injury were seen. CONCLUSION No difference in bone mineral density dependent on spasticity was detected in this study, but all included participants showed osteopaenia or osteoporosis at the hip, but not in full body values. Individuals with severe spasticity had greater muscle mass compared with those with no or mild spasticity.

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.

Traumatic spinal cord injury in Botswana: characteristics, aetiology and mortality.

Study design:Descriptive study with a cross-sectional design.Objectives:To describe the epidemiology of traumatic spinal cord injuries (TSCIs) in Botswana, with a specific focus on road traffic crashes (RTC).Setting:Main public referral hospital, Gaborone, Botswana.Method:Two samples were included. Sample one described the epidemiology and included patients admitted during a 2-year period with acute TSCI. Sample two included only patients with TSCI due to RTC.Results:Annual incidence was 13 per million population. Epidemiology of TSCI: 49 patients were included, 71% male, age ranging from 4 to 81 years, 80% ⩽45 years. Tetraplegia was more common than paraplegia (59/41%), and 39% had C1–C4 level of injury. The main cause of TSCI was RTC (68%), followed by assault (16%) and falls (10%). Mortality was 20%, where all, but one, had tetraplegia (18%). Median time from injury to spinal surgery was 12 days, with longer time for women, 16 days compared with 8 for men. Burst tire was the primary cause of RTC resulting in a TSCI, followed by hitting animals on the road. The majority had been passengers and 72% were involved in single crashes.Conclusion:The most common cause for TSCI was RTC, followed by assault. In-hospital mortality was high and the waiting period from the time of accident to spinal surgery was long, especially for women. The aetiology and high mortality of TSCI in Botswana indicate that improvements in roadway safety and medical care may decrease the TSCI incidence and mortality.

A prospective study of pain and psychological functioning following traumatic spinal cord injury

Study design:Longitudinal study.Objectives:To study prospectively pain characteristics, change in pain over time and the associations between pain and psychological functioning in adults with traumatic spinal cord injury (SCI).Setting:Neurosurgical departments, SCI rehabilitation centres and the community.Methods:Adults with traumatic SCI admitted over a 3-year period to two neurosurgical departments underwent clinical examination and questionnaires within 3 months after injury (baseline) and at 6, 12 and 42 months following SCI. Pain intensity and interference within the last 7 days, a global quality of life (QoL) item, the 5-item Mental Health Index and the 6-item Catastrophizing scale were used.Results:Ninety individuals were recruited, of which 81 completed a telephone interview on average 3.5 (s.d., 0.6) years after the SCI. Pain was present in 75% at 3.5 years. Baseline pain catastrophizing scores did not predict pain intensity at 3.5 years. Both psychological functioning and QoL increased over time. QoL scores increased less in participants who reported an increase in pain intensity from baseline to the 3.5-year follow-up, and the change in QoL score correlated with the change in pain interference. Neuropathic pain had an onset within the first 12 months and tended to become persistent, whereas musculoskeletal pain more often had a late onset or resolved in cases of early onset.Conclusions:A large proportion of SCI participants continue to experience pain many years after SCI. Teaching individuals with SCI skills to minimise pain’s impact on function as soon as possible following injury may prove beneficial.