Gender and minority differences in the pain experience of people with spinal cord injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated

The association of race, cultural factors, and health-related quality of life in persons with spinal cord injury

OBJECTIVE

To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI).

DESIGN

Cross-sectional multisite study using structured questionnaires.

SETTING

Six National SCI Model Systems centers.

PARTICIPANTS

People with SCI (N=275; age ≥16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey).

RESULTS

African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001-<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.07-2.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.12-2.43; P<.05) and greater perceived health (β=.36; 95% CI, .05-.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (β=.38; 95% CI, .06-.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.05-2.13; P<.05) and better general health (β=.27; 95% CI, .01-.53; P<.05).

CONCLUSIONS

In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being. These associations are different from those reported in other study populations and warrant confirmation in future prospective studies.

Future directions for spinal cord injury research: recent developments and model systems contributions

The authors look forward and discuss future directions in spinal cord injury (SCI) from a perspective of biomedical, psychosocial and technologic research. This discussion is based both on recent developments from various fields of knowledge and, more specifically, on SCI Model Systems' research contributions to medical rehabilitation. Biomedical research, as described here, includes (1) the process of moving from the "bench to bedside" and harnessing knowledge from basic science to produce new clinical treatment options for SCI during the life span; (2) the rapid proliferation of clinical trials aimed at neurologic recovery; (3) the growth of new technologies to restore and improve function; and (4) the challenges of developing relevant outcome measures to evaluate efficacy and effectiveness of interventions. Recent progress in psychosocial research has contributed significantly to understanding of the many factors associated with disability during the life course, the importance of quality of life issues, and the value of activity, participation, and the environment in promoting successful rehabilitation outcomes following SCI. Technology and bioengineering advances are discussed in relation to access to high-quality technology; restoration and replacement of movement; and technology to enhance rehabilitation outcomes.

Vulnerable Groups Living with Spinal Cord Injury

There is considerable variation in rehabilitation outcomes within the population of spinal cord-injured individuals across racial and socioeconomic groups. This suggests that the long-term health following spinal cord injury (SCI) is determined, at least in part, by group differences in exposure to advantages and disadvantages among persons living in the community. This article conceptualizes the nature of vulnerability and how increased vulnerability leads to disparities in SCI outcomes. Demographic, socioeconomic, and geographic determinants of adverse outcomes among vulnerable groups are discussed. Finally, a research model that outlines potential processes that elicit vulnerability following SCI and clinical implications is reviewed.

A systematic review of pharmacologic treatments of pain after spinal cord injury

OBJECTIVE

To conduct a systematic review of published research on the pharmacologic treatment of pain after spinal cord injury (SCI).

DATA SOURCES

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles published 1980 to June 2009 addressing the treatment of pain post SCI. Randomized controlled trials (RCTs) were assessed for methodologic quality using the Physiotherapy Evidence Database (PEDro) assessment scale, whereas non-RCTs were assessed by using the Downs and Black (D&B) evaluation tool. A level of evidence was assigned to each intervention by using a modified Sackett scale.

STUDY SELECTION

The review included RCTs and non-RCTs, which included prospective controlled trials, cohort, case series, case-control, pre-post studies, and post studies. Case studies were included only when there were no other studies found.

DATA EXTRACTION

Data extracted included the PEDro or D&B score, the type of study, a brief summary of intervention outcomes, the type of pain, the type of pain scale, and the study findings.

DATA SYNTHESIS

Articles selected for this particular review evaluated different interventions in the pharmacologic management of pain after SCI. Twenty-eight studies met inclusion criteria; there were 21 randomized controlled trials; of these, 19 had level 1 evidence. Treatments were divided into 5 categories: anticonvulsants, antidepressants, analgesics, cannabinoids, and antispasticity medications.

CONCLUSIONS

Most studies did not specify participants' types of pain, making it difficult to identify the type of pain being targeted by the treatment. Anticonvulsant and analgesic drugs had the highest levels of evidence and were the drugs most often studied. Gabapentin and pregabalin had strong evidence (5 level 1 RCTs) for effectiveness in treating post-SCI neuropathic pain as did intravenous analgesics (lidocaine, ketamine, and morphine), but the latter only had short-term benefits. Tricyclic antidepressants only showed benefit for neuropathic pain in depressed persons. Intrathecal baclofen reduced musculoskeletal pain associated with spasticity; however, there was conflicting evidence for the reduction in neuropathic pain. Studies assessing the effectiveness of opioids were limited and revealed only small benefits. Cannabinoids showed conflicting evidence in improving spasticity-related pain. Clonidine and morphine when given together had a significant synergistic neuropathic pain-relieving effect.

Pain among veterans with spinal cord injury

The Department of Veterans Affairs Veterans Health Administration cares for approximately 15% of persons with spinal cord injury (SCI) in the United States. However, the nature and characteristics of pain among veterans with SCI are not well understood. This study used a postal survey to compare veterans with SCI and nonveterans with SCI on pain intensity; pain interference; functioning; and other pain, demographic, and medical characteristics. Veterans tended to be older than nonveterans but these groups were otherwise comparable on demographic and medical variables. Veterans were not significantly different from nonveterans on pain intensity or pain interference. Veterans reported lower levels of functioning than nonveterans and higher levels of pain-related catastrophizing. However, differences in functioning between veterans and nonveterans were attributable to age differences between the groups. In summary, differences between veterans with SCI and nonveterans with SCI were few and small in magnitude, suggesting that veterans with SCI are not at greater risk for pain and pain-related problems. However, pain-related catastrophizing may be a particular concern among veterans with SCI.

Neuropathic pain in spinal cord injury: identification, classification, evaluation

OBJECTIVE

Chronic pain is very frequent after spinal cord injury, recent data showing that at least 80% of the patients experience pain, one-third at a severe level. The main objective of the present work is to report and discuss data regarding tools and procedures for the screening, diagnosis, and evaluation of neuropathic pain in spinal cord injury patients.

MATERIAL AND METHOD

The method used is that developed by the SOFMER, which associated a systematic review of the literature and a selection of published works by a scientific commitee, an analysis of data performed by a binom neuropathic pain/physical medicine and rehabilitation (PM&R) specialists, an evaluation of current practices during an expert consensus conference and via Internet, and finally a validation of the whole work by a pluridisciplinary expert panel.

RESULTS

The literature provides an important series of studies on pain in spinal injury, but without specific data about neuropathic pain in this population. Some specific diagnostic and evaluation tools for neuropathic pain have been developed these last years, while numerous classifications, based on various criteria, have been proposed, some of them exhibiting some advantages for a pragmatic application and being in parallel in accordance with recent nosological and physiopathological advances.

DISCUSSION

The DN4 questionnaire can be used for the screening and identification of neuropathic pain in this population of patients, often suffering from various types of pain. The use of the Spinal Cord Injury Pain Task Force of the International Association of the Study of Pain classification (SCIP-IASP), although some limitations, is recommended since taking into account physiopathology, localisation, and nature of pain. Daily uses of Visual Analogic Scale (VAS) or Numeric Scale (NS) are an obvious need and that of the questionnaire Douleur de Saint-Antoine (QDSA) for global evaluation and more specifically of the Neuropathic Pain Symptom Inventory (NPSI) for neuropathic pain are highly recommended.

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

OBJECTIVE

Analyze the epidemiological data on neuropathic pain in spinal cord injury patients and determine the risk factors for its occurrence and chronicity.

METHOD

Review and analysis of the literature.

RESULTS

Epidemiological 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.

CONCLUSION

Neuropathic pain in SCI patients is a major issue, its determining factors still need to be evaluated properly by refining the epidemiological data.

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

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.

The relationship of shoulder pain intensity to quality of life, physical activity, and community participation in persons with paraplegia

BACKGROUND/OBJECTIVE

For persons with spinal cord injury (SCI), severe bodily pain is related to a lower quality of life. However, the effect of pain from a specific body region on quality of life has yet to be determined. The shoulder joint is a common site of pain among persons with SCI. Therefore, our purpose was to identify the relationship of self-reported shoulder pain with quality of life, physical activity, and community activities in persons with paraplegia resulting from SCI.

METHODS

Eighty participants with shoulder pain who propel a manual wheelchair (mean age: 44.7 years; mean duration of injury: 20 years; injury level T1-L2) completed the following questionnaires: Wheelchair User's Shoulder Pain Index, Subjective Quality of Life Scale, Physical Activity Scale for Individuals with Physical Disabilities, and Community Activities Checklist. Correlations between shoulder pain scores and quality of life, physical activity, and community activities were determined using Spearman's rho test.

RESULTS

Shoulder pain intensity was inversely related to subjective quality of life (r(s) =-0.35; P= 0.002) and physical activity (r(s) = -0.42; P < 0.001). Shoulder pain intensity was not related to involvement in community activities (r(s) = -0.07; P = 0.526).

CONCLUSIONS

Persons with SCI who reported lower subjective quality of life and physical activity scores experienced significantly higher levels of shoulder pain. However, shoulder pain intensity did not relate to involvement in general community activities. Attention to and interventions for shoulder pain in persons with SCI may improve their overall quality of life and physical activity.

Influence of age and gender on rehabilitation outcomes in nontraumatic spinal cord injury

STUDY DESIGN

Retrospective, 3-year case series.

OBJECTIVE

To investigate the relationship between gender and age and a range variables in patients with nontraumatic spinal cord injury (SCI).

SETTING

Tertiary medical unit specializing in rehabilitation of patients with nontraumatic SCI.

METHOD

Participants were a consecutive series of 70 adult inpatients with nontraumatic SCI undergoing initial rehabilitation. The variables of interest were demographic characteristics, clinical features, complications, mortality, length of stay (LOS), mobility, bladder and bowel continence, and Functional Independence Measure (FIM) scores.

RESULTS

Men were younger than women, but the difference was not statistically significant (median 64 years vs 72.5 years, P= 0.2). There was no statistically significant relationship between age or gender and the following: American Spinal Injury Association grade, level of injury, many SCI complications, mortality, LOS, walking ability, bladder management, and fecal continence. The only SCI complication that was related to age was pressure ulcers (<65 years = 20% vs >65 years = 50%, P = 0.04). Patients discharged home were more likely to be younger (P = 0.01) and male (P = 0.03). There was a significant negative correlation between patients' age and the discharge Rasch-transformed FIM motor (Spearman's p = -0.30, P = 0.015) and cognitive (Spearman's p = -0.25, P = 0.04) subscores. There were no significant relationships between gender and FIM subscale scores.

CONCLUSIONS

Gender and age do not significantly influence most aspects of rehabilitation in patients with nontraumatic SCI. Age alone should not be used as a discriminator of ability to benefit from nontraumatic SCI rehabilitation.

Treatments for chronic pain in persons with spinal cord injury: A survey study

BACKGROUND/OBJECTIVE

To determine the degree and duration of pain relief provided by specific pain treatments used by individuals with spinal cord injury (SCI) who have chronic pain.

DESIGN

Postal survey.

SETTING

Community.

PARTICIPANTS

Participants were 117 individuals who had traumatic SCI, were 18 years of age or older, and reported a chronic pain problem.

MAIN OUTCOME MEASURES

Questions assessing current or past use of 26 different pain treatments, the amount of relief each treatment provided, and the length of time that any pain relief usually lasts.

RESULTS

The medications tried most often were nonsteroidal anti-inflammatory drugs (tried by 71%) and acetaminophen (tried by 70%); these medications were still being used by more than one half of the patients who had tried them. Opioids produced the greatest degree of pain relief on average (mean, 6.27 +/- 3.05 [SD] on a 0-10 scale, with 0 = no relief and 10 = complete relief) but were unlikely to be continued by those who tried them. Although 38% of respondents with pain had tried gabapentin, only 17% were still using it, and average pain relief was only moderate (mean, 3.32 +/- 3.03 on the 0-10 relief scale). Seventy-three percent of the respondents had tried at least 1 of 7 alternative pain treatments, and the most frequently tried were massage, marijuana, and acupuncture. The most relief was provided by massage (mean, 6.05 +/- 2.47] on the 0-10 relief scale) and marijuana (mean, 6.62 +/- 2.54 on the 0-10 relief scale). The relief from the various treatments, including most medications, tended to last only minutes or hours; however, pain relief from alternative treatments such as massage, acupuncture, and hypnosis was reported to last for days in 25% to 33% of those who tried these treatments.

CONCLUSIONS

Many patients are not finding adequate pain relief from commonly prescribed medications. Alternative therapies should be considered as additional treatment options in this population.

Health-related quality of life in persons with traumatic spinal cord lesion in Helsinki

OBJECTIVE

To estimate the health-related quality of life (HRQoL) of persons with spinal cord lesion.

DESIGN

The study design was cross-sectional.

SUBJECTS

All adult citizens in Helsinki with traumatic spinal cord lesion were identified. The final study group comprised 117 subjects, corresponding to a participation rate of 77%.

METHODS

HRQoL was assessed by a generic 15-dimensional self-administered instrument (15D). Clinical examination was based on the manual of the American Spinal Injury Association. Examinations were performed on all subjects by the same experienced physician and physiotherapist.

RESULTS

The average 15D score of the study group was significantly lower (p<0.001) than that measured in the age-matched general population sample. Subjects with spinal cord lesion had significantly more problems due to the neurological lesion but also on the dimensions of sleeping, discomfort and symptoms and vitality. In regression analysis of the study group the only variable explaining HRQoL was the neurological level of the lesion. Spinal cord lesion caused more depression and distress in persons with motor incomplete lesion than those with motor complete lesion.

CONCLUSION

Persons with spinal cord lesion had lower HRQoL than the population in general. The results indicate that spinal cord lesion may cause problems in the areas of sleeping, discomfort and symptoms or vitality, in particular. More attention should be paid to finding ways of improving the situation of persons with motor incomplete lesion, especially in terms of psychological function.

Cluster Analysis and Chronic Pain: An Empirical Classification of Pain Subgroups in a Spinal Cord Injury Sample

OBJECTIVE

To demonstrate the presence of homogeneous spinal cord injury (SCI) pain subgroups.

DESIGN

Prospective longitudinal design.

PARTICIPANTS

Persons with traumatic onset SCI (n = 1,334) with self-reported pain, pain interference, and depression.

OUTCOME MEASURES

Pain (Verbal Analogue Scale); Pain Interference (item from Short Form 12); Depression (Brief Patient Health Questionnaire).

RESULTS

Multivariate clustering indicated four SCI pain subgroups: (1) Low Pain (low pain intensity, pain interference, and depression); (2) Positive Adaptation to Pain (high pain intensity, low pain interference and depression); (3) Minimal Distress (high pain intensity, high pain interference, and low depression); and (4) Chronic Pain Syndrome (high pain intensity, pain interference, and depression).

CONCLUSIONS

Homogeneous SCI pain subgroups may be important for clinicians to consider in treatment planning and research.

Research from the Model Spinal Cord Injury Systems: findings from the current 5-year grant cycle

This issue of the Archives of Physical Medicine and Rehabilitation is dedicated to current research findings of the Model Spinal Cord Injury Systems (MSCIS) program. The MSCIS grants were established by the Rehabilitation Services Administration in the 1970s. Now administered by the National Institute on Disability and Rehabilitation Research within the Office of Special Education and Rehabilitation Services in the US Department of Education, the program has included 27 spinal cord injury centers in the United States over the years. In the current 5-year grant cycle (2000-2005), there are 16 designated regional MSCIS centers. In addition to establishing a comprehensive system of care, the grantees contribute patient data to the National Spinal Cord Injury Database (which now contains data on 30,532 subjects with follow-up of up to 30 y). In addition, the MSCIS grants enable the conduct of site-specific and collaborative research projects. To highlight the research findings of the program, the MSCIS have produced a special dissemination effort during each of the previous 5 grant cycles, with this issue of the Archives representing the latest of these endeavors. This article provides a brief history of the MSCIS program and highlights the important findings of the 17 original research articles contained in this issue.