Eva G. Widerström-Noga

Perceived difficulty in dealing with consequences of spinal cord injury

OBJECTIVES To determine the perceived difficulty in dealing with consequences of spinal cord injury (SCI) and to explore patterns of how these complications are perceived. DESIGN Postal survey. SETTING General community. PARTICIPANTS Individuals with traumatic SCI (n = 430). METHODS Subjects (n = 877) were selected from The Miami Project database and were sent a questionnaire in which they were asked to rate their difficulty in dealing with 10 consequences of SCI, on a scale ranging from 0 (not hard at all) to 10 (extremely hard). RESULTS The questionnaire was returned by 430 individuals (49%). Five consequences (decreased ability to walk or move, decreased control of bowel, decreased control of bladder, decreased sexual function, and pain) were rated highest (means, 8.2 to 6.2). High ratings of feeling sad were associated with high ratings of most other consequences, and a cluster analysis revealed interrelationships between the ways the various consequences were perceived. CONCLUSIONS Several consequences of SCI are frequently perceived as being very difficult to deal with. Sadness may influence how well a person deals with other consequences of SCI. The observed patterns in perceived difficulty dealing with complications of SCI need to be explored further because they are important in our understanding and treatment of the medical conditions that may follow SCI.

The international spinal cord injury pain basic data set.

Objective:To develop a basic pain data set (International Spinal Cord Injury Basic Pain Data Set, ISCIPDS:B) within the framework of the International spinal cord injury (SCI) data sets that would facilitate consistent collection and reporting of pain in the SCI population.Setting:International.Methods:The ISCIPDS:B was developed by a working group consisting of individuals with published evidence of expertise in SCI-related pain regarding taxonomy, psychophysics, psychology, epidemiology and assessment, and one representative of the Executive Committee of the International SCI Standards and Data Sets. The members were appointed by four major organizations with an interest in SCI-related pain (International Spinal Cord Society, ISCoS; American Spinal Injury Association, ASIA; American Pain Society, APS and International Association for the Study of Pain, IASP). The initial ISCIPDS:B was revised based on suggestions from members of the Executive Committee of the International SCI Standards and Data Sets, the ISCoS Scientific Committee, ASIA and APS Boards, and the Neuropathic Pain Special Interest Group of the IASP, individual reviewers and societies and the ISCoS Council.Results:The final ISCIPDS:B contains core questions about clinically relevant information concerning SCI-related pain that can be collected by health-care professionals with expertise in SCI in various clinical settings. The questions concern pain severity, physical and emotional function and include a pain-intensity rating, a pain classification and questions related to the temporal pattern of pain for each specific pain problem. The impact of pain on physical, social and emotional function, and sleep is evaluated for each pain.

Pain after spinal cord injury: an evidence-based review for clinical practice and research. Report of the National Institute on Disability and Rehabilitation Research Spinal Cord Injury Measures meeting.

Abstract Background/Objectives: To examine the reliability, validity, sensitivity, and practicality of various outcome measures for pain after spinal cord injury (SCI), and to provide recommendations for specific measures for use in clinical trials. Data Sources: Relevant articles were obtained through a search of MEDLINE, EMBASE, CINAHL, and PubMed databases from inception through 2006. Study Selection: The authors performed literature searches to find articles containing data relevant to the reliability and validity of each pain outcome measure in SCI and selected non-SCI populations. Data Extraction: After reviewing the articles, an investigator extracted information utilizing a standard template. A second investigator reviewed the chosen articles and the extracted pertinent information to confirm the findings of the first investigator. Data Synthesis: Taking into consideration both the quantity and quality of the studies analyzed, judgments on reliability and validity of the measures were made by the two investigators. Based upon these judgments, recommendations were formulated for use of specific measures in future clinical trials. In addition, for a subset of measures a voting process by a larger group of SCI experts allowed formulation of recommendations including determining which measures should be incorporated into a minimal dataset of measures for clinical trials and which ones need revision and further validity and reliability testing before use. Conclusions: A 0-10 Point Numerical Rating Scale (NRS) is recommended as the outcome measure for pain intensity after SCI, while the 7-Point Guy/Farrar Patient Global Impression of Change (PGIC) scale is recommended as the outcome measure for global improvement in pain. The SF-36 single pain interference question and the Multidimensional Pain Inventory (MPI) or Brief Pain Inventory (BPI) pain interference items are recommended as the outcome measures for pain interference after SCI. Brush or cotton wool and at least one high-threshold von Frey filament are recommended to test mechanical allodynia/hyperalgesia while a Peltier-type thermotester is recommended to test thermal allodynia/hyperalgesia. The International Association for the Study of Pain (IASP) or Bryce-Ragnarsson pain taxonomies are recommended for classification of pain after SCI, while the Neuropathic Pain Scale (NPS) is recommended for measuring change in neuropathic pain and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) for quantitating neuropathic and nociceptive pain discrimination.

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.

Biopsychosocial Perspective on a Mechanisms-Based Approach to Assessment and Treatment of Pain Following Spinal Cord Injury

This article applies a biopsychosocial perspective to a mechanisms-based approach to the assessment and treatment of the heterogeneous and persistent pain conditions associated with spinal cord injury (SCI). This article presents an overview of the types of pains experienced after SCI and some of the research on the mechanisms, diagnostic issues, and psychosocial factors relevant for the development of treatments targeting specific underlying mechanisms of pain. This review also discusses several diagnostic challenges of determining the underlying causes of pain in each individual patient.

Psychosocial profiles of people with pain associated with spinal cord injury: identification and comparison with other chronic pain syndromes.

Objectives:The objectives of the study were to: (1) identify psychosocial profiles of people with pain associated with spinal cord injuries (SCI), and (2) compare the psychosocial profiles with other chronic pain syndromes. Methods:History questionnaires and the Multidimensional Pain Inventory (MPI) were mailed to 159 persons with chronic pain and SCIs (SCICP) and 120 (75.5%) agreed to participate. Results:Cluster analysis of MPI scores identified 2 subgroups of SCICP. One (42.5%) was characterized by high Pain Severity (PS), Affective Distress (AD), Life Interference (LI), and low Life Control (LC) similar to a previously identified cluster labeled Dysfunctional. The second (57.5%) was characterized by low PS, AD, LI, and high levels of LC and activity (GA), similar to the Adaptive Copers (AC) cluster identified in previous studies with the exception that the scores were lower on Support (S), Solicitous Responses (SR), and Negative Responses (NR) and higher on Distracting Responses (DR). Both subgroups were similar to those observed in other chronic pain syndromes (CPSs). People with SCIs differed significantly from heterogeneous chronic pain and chronic headaches in that they indicated less inference of pain with activities. They also scored lower on S. SCICP reported comparable levels of LI, LC, AD, S, SR, but greater levels of PS compared with a group of people with post-polio syndrome. Discussion:The similarities and differences between SCI and other CPSs suggest that although a general measure assessing psychosocial impact can be used across pain syndromes, it is important to use different norms for comparison of particular pain syndromes. The failure to identify a subgroup of patients characterized by low levels of S and high levels of NR, and the low SR and DR for SCICP compared with other CPSs warrants examination.

Reliability and validity of the International Spinal Cord Injury Basic Pain Data Set items as self-report measures

Objective:To evaluate the psychometric properties of a subset of International Spinal Cord Injury Basic Pain Data Set (ISCIBPDS) items that could be used as self-report measures in surveys, longitudinal studies and clinical trials.Setting:Community.Methods:A subset of the ISCIBPDS items and measures of two validity criteria were administered in a postal survey to 184 individuals with spinal cord injury (SCI) and pain. The responses of the participants were evaluated to determine: (1) item response rates (as an estimate of ease of item completion); (2) internal consistency (as an estimate of the reliability of the multiple-item measures); and (3) concurrent validity.Results:The results support the utility and validity of the ISCIBPDS items and scales that measure pain interference, intensity, site(s), frequency, duration and timing (time of day of worst pain) in individuals with SCI and chronic pain. The results also provide psychometric information that can be used to select from among the ISCIBPDS items in settings that require even fewer items than are in the basic data set.

The International Spinal Cord Injury Pain Basic Data Set (version 2.0)

Objectives:To revise the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) based on new developments in the field and on suggestions from the spinal cord injury (SCI) and pain clinical and research community.Setting:International.Methods:The ISCIPBDS working group evaluated suggestions regarding the utility of the ISCIPBDS and made modifications in response to these and to significant developments in the field. The revised ISCIPBDS (version 2.0) was reviewed by members of the Executive Committee of the International SCI Standards and Data Sets, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, the American Spinal Injury Association and American Pain Society Boards and the Neuropathic Pain Special Interest Group of the International Association for the Study of Pain, individual reviewers and societies and the ISCoS Council.Results:The ISCIPBDS (version 2.0) is significantly shortened but still contains clinically relevant core questions concerning SCI-related pain. The revisions include an updated SCI pain classification, omission of three questions regarding temporal pain pattern and three pain interference questions. The remaining three pain interference questions concern perceived interference with activities, mood and sleep for overall pain rather than for individual pain problems and are scored on a 0 to 10 scale.

Metabolite concentrations in the anterior cingulate cortex predict high neuropathic pain impact after spinal cord injury

Summary Severe, high‐impact neuropathic pain after spinal cord injury was associated with anterior cingulate cortex metabolite concentrations, indicating a combination of glutamatergic metabolism and increased glia and glial activation. ABSTRACT Persistent pain is a common reason for reduced quality of life after a spinal cord injury (SCI). Biomarkers of neuropathic pain may facilitate translational research and the understanding of underlying mechanisms. Research suggests that pain and affective distress are anatomically and functionally integrated in the anterior cingulate cortex and can modulate sensory and affective aspects of pain. We hypothesized that severe neuropathic pain with a significant psychosocial impact would be associated with metabolite concentrations (obtained by magnetic resonance spectroscopy) in the anterior cingulate cortex, indicating neuronal and/or glial dysfunction. Participants with SCI and severe, high‐impact neuropathic pain (SCI‐HPI; n = 16), SCI and moderate, low‐impact neuropathic pain (SCI‐LPI; n = 24), SCI without neuropathic pain (SCI‐noNP; n = 14), and able‐bodied, pain‐free control subjects (A‐B; n = 22) underwent a 3‐T magnetic resonance imaging brain scan. Analyses revealed that the SCI‐HPI group had significantly higher levels of myoinositol (Ins) (P < .000), creatine (P = .007), and choline (P = .014), and significantly lower levels of N‐acetyl aspartate/Ins (P = .024) and glutamate‐glutamine (Glx)/Ins (P = .003) ratios than the SCI‐LPI group. The lower Glx/Ins ratio significantly discriminated between SCI‐HPI and the A‐B (P = .006) and SCI‐noNP (P = .026) groups, displayed excellent test‐retest reliability, and was significantly related to greater pain severity, interference, and affective distress. This suggests that the combination of lower glutamatergic metabolism and proliferation of glia and glial activation are underlying mechanisms contributing to the maintenance of severe neuropathic pain with significant psychosocial impact in chronic SCI. These findings indicate that the Glx/Ins ratio may be a useful biomarker for severe SCI‐related neuropathic pain with significant psychosocial impact.

Understanding Therapeutic Benefits of Overground Bionic Ambulation: Exploratory Case Series in Persons With Chronic, Complete Spinal Cord Injury

OBJECTIVE To explore responses to overground bionic ambulation (OBA) training from an interdisciplinary perspective including key components of neuromuscular activation, exercise conditioning, mobility capacity, and neuropathic pain. DESIGN Case series. SETTING Academic research center. PARTICIPANTS Persons (N=3; 2 men, 1 woman) aged 26 to 38 years with complete spinal cord injury (SCI) (American Spinal Injury Association Impairment Scale grade A) between the levels of T1 and T10 for ≥1 year. INTERVENTION OBA 3d/wk for 6 weeks. MAIN OUTCOME MEASURES To obtain a comprehensive understanding of responses to OBA, an array of measures were obtained while walking in the device, including walking speeds and distances, energy expenditure, exercise conditioning effects, and neuromuscular and cortical activity patterns. Changes in spasticity and pain severity related to OBA use were also assessed. RESULTS With training, participants were able to achieve walking speeds and distances in the OBA device similar to those observed in persons with motor-incomplete SCI (10-m walk speed, .11-.33m/s; 2-min walk distance, 11-33m). The energy expenditure required for OBA was similar to walking in persons without disability (ie, 25%-41% of peak oxygen consumption). Subjects with lower soleus reflex excitability walked longer during training, but there was no change in the level or amount of muscle activity with training. There was no change in cortical activity patterns. Exercise conditioning effects were small or nonexistent. However, all participants reported an average reduction in pain severity over the study period ranging between -1.3 and 1.7 on a 0-to-6 numeric rating scale. CONCLUSIONS OBA training improved mobility in the OBA device without significant changes in exercise conditioning or in neuromuscular or cortical activity. However, pain severity was reduced and no severe adverse events were encountered during training. OBA therefore opens the possibility to reduce the common consequences of chronic, complete SCI such as reduced functional mobility and neuropathic pain.