Anticonvulsant medication use for the management of pain following spinal cord injury: systematic review and effectiveness analysis

Models of care for musculoskeletal shoulder pain in spinal cord injury: A scoping review

CONTEXT

Spinal cord injury (SCI) is a neurological condition that significantly impacts a person's lifestyle, health and well-being. Many individuals with SCI experience secondary musculoskeletal shoulder pain. This scoping review examines the current research on the diagnosis and management of shoulder pain in SCI.

OBJECTIVE

The aim of this Scoping Review was (1) to chart peer-reviewed literature regarding the diagnosis and management of shoulder pain as it relates to SCI and (2) identify gaps in this body of literature to inform future research priorities.

METHODS

Six electronic databases were searched from inception until April 2022. In addition, reviewers scanned the reference lists of identified articles. Articles from peer-reviewed sources that reported diagnostic or management procedures for musculoskeletal shoulder conditions within the SCI population were considered and 1679 articles were identified. Title and abstract screening, full text review, and data extraction were undertaken by two independent reviewers.

RESULTS

Eighty seven articles were included, covering diagnosis or management of shoulder pain in SCI.

CONCLUSION

Whilst the most commonly reported diagnostic procedures and management strategies reflect contemporary practice for shoulder pain, the entire body of literature demonstrates inconsistencies in methodologies. In places, the literature continues to perceive value in procedures inconsistent with best practice. These findings encourage researchers to pursue the development of robust models of care for musculoskeletal shoulder pain in SCI using a collaborative and integrated approach, combining best practice for musculoskeletal shoulder pain alongside clinical expertise in the management of SCI.

Exploring the Experience of Living with Pain after Spinal Cord Injury: A Qualitative Study

A spinal cord injury is a life-changing experience that results in functional limitations and an increased risk of secondary health conditions. People with spinal cord injury identify pain as the most devastating health problem following their injury that not only affects their social life but their mental well-being as well. This study is aimed at exploring the lived experience of living with pain by community-dwelling manual wheelchair users with spinal cord injuries. An explorative qualitative design was used to explore their experiences. In-depth interviews were recorded and transcribed, and the data were analysed using inductive thematic content analysis in the MAXQDA v2020. Fifteen manual wheelchair users with paraplegia participated in this study, and four themes were identified from their experience of living with pain: pain constantly lurks, pain is worse than the direct consequences of the SCI, pain is restrictive, and life continues despite the pain. Categories and subcategories included the participants being one with the pain; pain interfering with sleep; feelings of anger, isolation, and suicidal ideation; and uncertainties about what the future holds living with pain. Living with pain after SCI is a challenging feat, and effective management of pain is necessary to improve not only functioning and mobility but also mental health and life satisfaction.

Pain medication misuse in the South African spinal cord injury context

Background

Pain after spinal cord injury (SCI) is debilitating and has been reported to be difficult to treat, despite pharmacological interventions. Pain medication misuse (PMM) and associated individual factors among people with spinal cord injury (PWSCI) are scarce.

Aim

To determine PMM and the associated factors in PWSCI.

Setting

Homes of community-dwelling manual wheelchair users with SCI in South Africa.

Methods

Community-dwelling PWSCI (n = 122) were consecutively sampled and the Pain Medication Questionnaire (PMQ) was used to determine PMM. Descriptive statistics, Fisher's exact test, independent t-tests, and simple linear regression tests were performed using SPSS v27. Testing was conducted at the 0.05 level of significance.

Results

Eighty-five per cent of the participants reported the presence of pain and 48.1% of them used pain medication. Forty-four percent of people who used pain medication scored ≥ 30, indicative of serious aberrant drug-taking behaviours. Opioids were mainly used for neuropathic pain and in combination with other types of medications such as anticonvulsants and non-steroidal anti-inflammatories (44.0%). Pain severity and the type of pain medication were found to be predictors of PMM (p < 0.01 respectively).

Conclusion

Pain relief after SCI remains difficult to achieve, with an evident high risk of PMM, which may lead to long-lasting side effects, dependency, or overdose.

Contribution

This study has shown the need for the assessment of the potential risk of dependency before prescribing pain medication, particularly opioids to PWSCI.

Development of a pain self-management intervention framework for people with spinal cord injury

BACKGROUND

 Pain is the most common reason for medical visits to primary health care practitioners. Pain self-management interventions are encouraged and there is no known self-management intervention framework available that clinicians and people with spinal cord injury (PWSCI) can use to guide treatment selection.

AIM

 This study aimed to develop a pain self-management intervention framework for PWSCI.

SETTING

 Online and facilitated in Gauteng, South Africa.

METHODS

 A three-round modified e-Delphi method was used to reach an 80% consensus among a 21-expert panel. Fifty-nine interventions were distributed via REDCap and a final online audio meeting was held to either include or exclude interventions in the final framework. SPSS v27 was used to analyse descriptive data and content analysis was used for qualitative responses.

RESULTS

 The final developed pain self-management framework consists of 56 interventions and includes interventions from multiple health professions to encompass medical, psychological, therapeutic and social interventions. Interventions are also specified for nociceptive and/or neuropathic pain and grouped according to the biopsychosocial model.

CONCLUSION

 The interprofessional framework may be used as a guideline for PWSCI to alleviate pain, as well as assist health professionals in clinical decision-making, by providing them with the freedom to choose acceptable and adequate interventions that may be appropriate to treat the affected individual's pain.Contribution: Pain management is a basic need at the primary healthcare level and PWSCI need access to the broad range of interventions available to manage their pain. The framework highlights the variety of appropriate interventions to guide both health professionals and PWSCI with pain relief options.

Non-opioid pharmacologic treatment of chronic spinal cord injury-related pain

Purpose: Spinal cord injury-related pain is often a severe debilitating condition that adversely affects the patient's physical health, psychological wellbeing and quality of life. Opioid medications have historically been prescribed to this population with great frequency. As opioid abuse disorder becomes an ever-worsening public health issue, more attention must be placed upon non-opioid options. This paper reviews non-opioid medications to be considered when treating spinal cord injury-related pain. The pertinent literature is reviewed, and the advantages and pitfalls of various medication options are discussed in the complicated context of the individual with a spinal cord injury.Methods: Peer-reviewed journal articles and medication package insert data are reviewed.Results:. The non-opioid medications with the greatest evidence for efficacy in the treatment of chronic spinal cord injury-related pain are drawn from the antiepileptic drug and antidepressant categories though the specific selection must be nuanced to the particular individual patient. More research is required to understand the role of calcitonin, lithium, and marijuana in treating spinal cord injury-related pain.Conclusions: The complex clinical situation of each individual patient must be weighed against the risks and benefits of each medication, as reviewed in this paper, to determine the ideal treatment strategy for chronic spinal cord injury-related pain.

Management of spinal cord injury-related pain using complementary alternative medicine: a scoping review protocol

OBJECTIVE

This scoping review will identify complementary alternative medicine methods used to manage spinal cord injury-related pain.

INTRODUCTION

Spinal cord injury-related pain is common, with a third of individuals experiencing severe pain. Conventional interventions are well documented, however, pain relief remains elusive for people with spinal cord injuries. Although complementary alternative medicine is available to alleviate various health problems, little is known about the complementary alternative medicine methods used to manage pain in people with spinal cord injuries.

INCLUSION CRITERIA

This review will consider all studies on complementary alternative medicine treatment methods used by adults with spinal cord injury to treat their associated pain. The concept of interest in this study is complementary alternative medicine. Quantitative, qualitative, and mixed methods studies, text and opinion papers as well as systematic reviews will be included in this review.

METHODS

A three-step search strategy, consisting of an initial limited search, a full search, and a screening of the reference lists of all included articles will be undertaken. Key information sources to be searched include CINAHL, Cochrane Library, JBI Evidence Synthesis, MEDLINE, Scopus, Web of Science, DynaMed, Natural Medicines, HerbMed, Open Dissertations, and OpenGrey. All titles and abstracts of identified citations will be screened and then uploaded to a reference management program. The full text of studies potentially meeting the inclusion criteria will be assessed in detail, and relevant data will be extracted and reported in tabular format, in line with the objectives and scope of the review.

On the therapeutic targets and pharmacological treatments for pain relief following spinal cord injury: A mechanistic review

Spinal cord injury (SCI) is globally considered as one of the most debilitating disorders, which interferes with daily activities and life of the affected patients. Despite many developments in related recognizing and treating procedures, post-SCI neuropathic pain (NP) is still a clinical challenge for clinicians with no distinct treatments. Accordingly, a comprehensive search was conducted in PubMed, Medline, Scopus, Web of Science, and national database (SID and Irandoc). The relevant articles regarding signaling pathways, therapeutic targets and pharmacotherapy of post-SCI pain were also reviewed. Data were collected with no time limitation until November 2020. The present study provides the findings on molecular mechanisms and therapeutic targets, as well as developing the critical signaling pathways to introduce novel neuroprotective treatments of post-SCI pain. From the pathophysiological mechanistic point of view, post-SCI inflammation activates the innate immune system, in which the immune cells elicit secondary injuries. So, targeting the critical signaling pathways for pain management in the SCI population has significant importance in providing new treatments. Indeed, several receptors, ion channels, excitatory neurotransmitters, enzymes, and key signaling pathways could be used as therapeutic targets, with a pivotal role of n-methyl-D-aspartate, gamma-aminobutyric acid, and inflammatory mediators. The current review focuses on conventional therapies, as well as crucial signaling pathways and promising therapeutic targets for post-SCI pain to provide new insights into the clinical treatment of post-SCI pain. The need to develop innovative delivery systems to treat SCI is also considered.

The Efficacy, Adverse Events & Withdrawal Rates of the Pharmacological Management of Chronic Spinal Cord Injury Pain: A Systematic Review & Meta-Analysis

OBJECTIVE

To establish the efficacy of medications, incidence of adverse events (AE) and withdrawal rates (WR) of the pharmacological management of chronic spinal cord injury (SCI) pain.

METHODOLOGY

PubMed, MEDLINE, Embase, CINAHL, Web of Science, CENTRAL and PsycINFO were searched (November 2017) and updated (January 2020). Two independent review authors screened and identified papers for inclusion.

RESULTS

Twenty-one studies met inclusion for efficacy analysis and 17 for AEs and WR analysis; no additional paper were included from the up dated 2020 search. Treatments were divided into 6 categories: anticonvulsants (n = 6), antidepressants (n = 3), analgesics (n = 8), anti-spasticity (n = 2), cannabinoids (n = 1) and other (n = 2). Trials of anticonvulsants, antidepressants, and cannabinoids included long-term follow-up trials (2 weeks- 4 months), and analgesics, anti-spasticity, among others were short term trials (0-2 days). Effectiveness for NP was found for Pregabalin (3/3 studies) and Lidocaine (2/3 studies). Studies using Ketamine also reported effectiveness (2/2) but the quality of these papers was rated as poor. Most frequently reported AEs included dizziness, dry mouth, nausea and constipation. Pregabalin had a higher risk of somnolence (RR 3.15, 95% CI 2.00-4.98) and dizziness (RR 2.9, 95% CI 1.58-5.30). Ketamine had a higher risk of reduced vision (RR 9.00, 95% CI 0.05-146.11), dizziness (RR 8.33, 95% CI 1.73-40.10) and somnolence (RR 7.00, 95% CI 1.73-40.1). WRs ranged from: 18.4% (antidepressants), 0-30% (anticonvulsants), 0-10% (anti-spasticity), 0-48% (analgesics), 28.6% (cannabinoids) and 0-22.2% (other).

CONCLUSION

Pregabalin was found to be effective for NP versus placebo. Cannabinoids was ineffective for NP. AEs are a common cause for withdrawal. The nature of AEs was poorly reported and should be improved in future RCT's.

Pain and its impact on functioning and disability in manual wheelchair users with spinal cord injury: a protocol for a mixed-methods study

INTRODUCTION

Approximately 80% of people with spinal cord injury experience clinically significant chronic pain. Pain (whether musculoskeletal or neuropathic) is consistently rated as one of the most difficult problems to manage and negatively affects the individual's physical, psychological and social functioning and increases the risk of pain medication misuse and poor mental health. The aim of this study is to therefore determine the presence of pain and its impact on functioning and disability as well as to develop a framework for self-management of pain for South African manual wheelchair users with spinal cord injury.

METHODS AND ANALYSIS

Community-dwelling participants with spinal cord injury will be invited to participate in this three-phase study. Phase 1 will use a quantitative, correlational design to determine factors related to pain such as pectoralis minor length, scapular dyskinesis, wheelchair functioning, physical quality of life, community reintegration and pain medication misuse. Demographic determinants of pain such as age, gender, type of occupation, completeness of injury and neurological level of injury will also be investigated. Participants with pain identified in phase 1 will be invited to partake in a qualitative descriptive and contextually designed phase 2 to explore their lived experience of pain through in-depth interviews. The results of phases 1 and 2 will then be used with the assistance from experts to develop a framework for self-management of pain using a modified Delphi study. Data analysis will include descriptive and inferential statistics (quantitative data) and thematic content analysis (qualitative data).

ETHICS AND DISSEMINATION

Approval for this study is granted by the Faculty of Health Sciences Research Ethics Committee of the University of the Pretoria (approval number 125/2018). This study is registered with the South African National Health Research Database (reference GP201806005). This study's findings will be shared in academic conferences and published in scientific peer-reviewed journals.

Involvement of Oxidative Stress and Nerve Growth Factor in Behavioral and Biochemical Deficits of Experimentally Induced Musculoskeletal Pain in Mice: Ameliorative Effects of Heraclin

Musculoskeletal pain is a widespread complex regional pain syndrome associated with altered emotional and cognitive functioning along with heightened physical disability that has become a global health concern. Effective management of this disorder and associated disabilities includes accurate diagnosis of its biomarkers and instituting mechanism-based therapeutic interventions. Herein, we explored the role of heraclin, a plant-derived molecule, in musculoskeletal pain and its underlying mechanistic approaches in an experimental mouse model. Reserpine (0.5 mg/kg) for 3 consecutive days evoked hyperalgesia, motor incoordination, lack of exploratory behavior, anxiety, and cognition lapse in mice. Reserpine-challenged mice displayed higher serum cytokine level, altered brain neurotransmitter content, elevated brain and muscle oxidative stress, and upregulated brain nerve growth factor receptor expression. Treatment with heraclin (10 mg/kg for 5 consecutive days) exerted analgesic effect and improved motor coordination and memory deficits in mice. Heraclin arrested serum cytokine rise, normalized brain neurotransmitter content, reduced tissue oxidative stress, and downregulated the nerve growth factor receptor expression. Therefore, it may be suggested that heraclin exerts beneficial effects against reserpine-induced musculoskeletal pain disorder possibly through the attenuation of NGFR-mediated pain and inflammatory signaling. Graphical Abstract.

Percutaneous Transforaminal Endoscopic Removal of Spinal Shrapnel

BACKGROUND

Gunshot injuries are one of the most common causes of the penetrating injuries of the spine. The victims of these injuries usually have neurologic deficits. Percutaneous endoscopic lumbar surgery is one of the most popular surgical spine interventions. We report a case with incomplete radiculopathy due to shrapnel located in L5 foramen that was removed by percutaneous endoscopic technique.

CASE DESCRIPTION

A 23-year-old man sustaining a gunshot injury penetrating to the abdomen presented to our hospital. His first examination revealed a single gunshot wound with entry hole in the left low lumbar region without exit hole and right lower abdominal quadrant tenderness. Plain radiographs and computed tomography showed a bullet in the abdomen and left L5 transverse process fracture and shrapnel in L5 foraminal zone. The bullet was removed by abdominal surgeons without any surgical plan for the shrapnel in the foramen. He was referred to our clinic 3 weeks after discharge. Without any further neurologic deterioration, he had uninterrupted severe pain that was mostly unbearable during the night. Despite gradually increasing dosages of different drugs, his pain relief was insufficient. Percutaneous transforaminal endoscopic removal of the shrapnel was planned.

CONCLUSIONS

Despite the absence of a universally approved algorithm in the treatment of spinal gunshot injuries, endoscopic technique can be kept in mind for a minimal access and invasiveness in case of indication for removal. With experience in endoscopic procedures and familiarity with surgical anatomy, the treatment of this unique case was completed successfully.

Pregabalin and gabapentin in neuropathic pain management after spinal cord injury: a systematic review and meta-analysis

Neuropathic pain after spinal cord injury (SCI) has a significant negative impact on the patients’ quality of life. The objective of this systematic review is to examine the safety and efficacy of pregabalin (PGB) and gabapentin (GBP) in the treatment of neuropathic pain due to SCI. PubMed, the Cochrane Library, Embase, Scopus, and the Web of Science were searched up to December 2018. The reference lists of key and review studies were reviewed for additional citations. The quality of the studies was evaluated using the Cochrane Collaboration’s tools for assessing the risk of bias. A meta-analysis was performed for primary and secondary outcomes. Eight studies were eligible for inclusion. Meta-analysis of PGB vs. placebo showed that PGB was effective for neuropathic pain (standardized mean difference [SMD] = −0.40; 95% confidence interval [CI]: −0.78, −0.01), anxiety (MD = −0.68; 95% CI: −0.77, −0.59), depression (mean difference [MD] = −0.99; 95% CI: −1.08, −0.89), and sleep interference (MD = −1.08; 95% CI: −1.13, −1.02). Also, GBP was more effective than a placebo for reducing pain. No significant difference was observed between the efficacy of the two drugs (MD = −0.37; 95% CI: −1.67, 0.93). There was no significant difference between the two drugs for discontinuation due to adverse events (risk ratio = 3.00; 95% CI: 0.81, 11.15). PGB and GBP were effective vs. placebos in decreasing neuropathic pain after SCI. Also, there was no significant difference between the two drugs for decreasing pain and adverse events.

The Effect of Non-Gabapentinoid Anticonvulsants on Sensorimotor Recovery After Human Spinal Cord Injury

BACKGROUND

Recent observational studies have shown an association between gabapentinoid anticonvulsants and greater motor recovery after spinal cord injury. There is preclinical evidence to suggest that other anticonvulsants, such as sodium channel blockers, may also confer beneficial effects.

PURPOSE

The aim of the current study was to determine if non-gabapentinoid anticonvulsants were associated with neurological recovery after acute, traumatic spinal cord injury.

METHODS

This was an observational cohort study using data from the Sygen clinical trial. The primary outcome was total motor score recovery in the first year after injury. Anticonvulsant use was extracted from concomitant medication records; individuals were classified based on early administration (within 30 days of injury), or late/no administration. Motor recovery was compared using linear mixed effects regression models with a drug-by-time interaction, and adjustment for confounders. A secondary analysis incorporated a propensity score matched cohort.

RESULTS

Of the cohort (n = 570), 6% received anticonvulsants (carbamazepine, phenytoin, clonazepam, phenobarbital, and valproic acid) early after injury. After adjustments for initial injury level and severity, early exposure to non-gabapentinoid anticonvulsants was not associated with motor neurological outcomes (p = 0.38 for all anticonvulsants, p = 0.83 for sodium channel blockers, p = 0.82 in propensity-matched cohort).

CONCLUSION

Non-gabapentinoid anticonvulsant exposure was not associated with greater or lesser neurological recovery. This suggests that these medications, as administered for the acute management of spinal cord injury, do not impact long-term neurological outcomes.

Repeated Sigma-1 Receptor Antagonist MR309 Administration Modulates Central Neuropathic Pain Development After Spinal Cord Injury in Mice

Up to two-thirds of patients affected by spinal cord injury (SCI) develop central neuropathic pain (CNP), which has a high impact on their quality of life. Most of the patients are largely refractory to current treatments, and new pharmacological strategies are needed. Recently, it has been shown that the acute administration of the σ1R antagonist MR309 (previously developed as E-52862) at 28 days after spinal cord contusion results in a dose-dependent suppression of both mechanical allodynia and thermal hyperalgesia in wild-type CD-1 Swiss female mice. The present work was addressed to determine whether MR309 might exert preventive effects on CNP development by repeated administration during the first week after SCI in mice. To this end, the MR309 (16 or 32 mg/kg i.p.) modulation on both thermal hyperalgesia and mechanical allodynia development were evaluated weekly up to 28 days post-injury. In addition, changes in pro-inflammatory cytokine (TNF-α, IL-1β) expression and both the expression and activation (phosphorylation) of the N-methyl-D-aspartate receptor subunit 2B (NR2B-NMDA) and extracellular signal-regulated kinases (ERK1/2) were analyzed. The repeated treatment of SCI-mice with MR309 resulted in significant pain behavior attenuation beyond the end of the administration period, accompanied by reduced expression of central sensitization-related mechanistic correlates, including extracellular mediators (TNF-α and IL-1β), membrane receptors/channels (NR2B-NMDA) and intracellular signaling cascades (ERK/pERK). These findings suggest that repeated MR309 treatment after SCI may be a suitable pharmacologic strategy to modulate SCI-induced CNP development.

Evaluating the effectiveness of antidepressant therapy adjuvant to gabapentin and pregabalin for treatment of SCI-related neuropathic pain

OBJECTIVE

To investigate if a combination of anticonvulsant and antidepressant, two primary therapies for neuropathic pain, is associated with improved pain control compared to individual therapy.

DESIGN

Prospective cohort study Setting: The University of Alabama at Birmingham Rehabilitation Center In-patient Program between 2012 and 2015.

PARTICIPANTS

Incident SCI cases, 19-65 years of age.

OUTCOMES

Bryce-Ragnarsson pain classification scheme and the Numerical Rating Scale Results: Twenty-nine eligible patients completed 6-month follow-up; their average age was 36.4 years, 89% were male, and 65% were white. Baseline characteristics were not different by therapy initiated (combination versus single). At 6 months follow-up, therapy initiated at baseline was not associated with level of pain in the past week (p=0.3145) or past 24 hours (p=0.4107). However, patients who remained on the same therapy reported lower levels of pain 30 minutes after waking (p=0.0235).

CONCLUSIONS

The initiation of a combination of anticonvulsant and antidepressant shortly after SCI was not associated with improved pain control at 6 months compared to individual therapy. Adherent patients reported lower levels of pain; further analysis is warranted to elucidate this association.

Evaluation of the antinociceptive activities of several sodium channel blockers using veratrine test in mice

An important role of voltage-gated sodium channels (VGSCs) in many different pain states has been established in animal models and humans wherein sodium channel blockers partially ameliorate pain. However, behavioral tests for screening analgesics that exhibit pharmacologic action by acting on VGSCs are rarely reported, and there are no studies on antinociception using veratrine as a nociceptive agent. The aim of the present study was to examine the amount of nociceptive behavior evoked by subcutaneous administration of veratrine into the hind paw and investigate whether veratrine can be used as a VGSC agonist to test the pharmacological properties of candidate analgesics via sodium channel blockade. We report for the first time that intraplantar injection of veratrine produced a reproducible nociceptive response in mice. Furthermore, several sodium channel blockers, namely carbamazepine, valproate, mexiletine, and the selective Nav1.7 inhibitor PF-04856264, but not flecainide or pilsicainide, reduced veratrine-induced nociception. In contrast, calcium channel blockers gabapentin and ethosuximide did not change veratrine-induced nociception. The veratrine test in mice might be a useful tool, at least in part, to evaluate the potential analgesic effect of sodium channel blockers.

Increased Levels of Circulating Glial Fibrillary Acidic Protein and Collapsin Response Mediator Protein-2 Autoantibodies in the Acute Stage of Spinal Cord Injury Predict the Subsequent Development of Neuropathic Pain

Neuropathic pain develops in 40-70% of spinal cord injury (SCI) patients and markedly compromises quality of life. We examined plasma from SCI patients for autoantibodies to glial fibrillary acidic protein (GFAP) and collapsin response mediator protein-2 (CRMP2) and evaluated their relationship to the development of neuropathic pain. In study 1, plasma samples and clinical data from 80 chronic SCI patients (1-41 years post-SCI) were collected and screened for GFAP autoantibodies (GFAPab). Results from study 1 indicated that GFAPab were present in 34 of 80 (42.5%) patients, but circulating levels did not correlate with the occurrence of neuropathic pain. In study 2, longitudinal plasma samples and clinical data were collected from 38 acute SCI patients. The level of GFAPab measured at 16 ± 7 days post-SCI was found to be significantly higher in patients that subsequently developed neuropathic pain (within 6 months post-SCI) than patients who did not (T = 219; p = 0.02). In study 3, we identified CRMP2 as an autoantibody target (CRMP2ab) in 23% of acute SCI patients. The presence of GFAPab and/or CRMP2ab increased the odds of subsequently developing neuropathic pain within 6 months of injury by 9.5 times (p = 0.006). Our results suggest that if a causal link can be established between these autoantibodies and the development of neuropathic pain, strategies aimed at reducing the circulating levels of these autoantibodies may have therapeutic value.

Pain in the Elderly: Identification, Evaluation, and Management of Older Adults with Pain Complaints and Pain-related Symptoms

Pain is a common and often underappreciated and undermanaged problem in older adults. This article addresses the scope of the issue of pain prevalence in older adults, types of pain and their characteristics, approach to and clinical workup of older adults with pain complaints and pain-related symptoms, nonpharmacologic and pharmacologic management strategies, and caveats with attention to medication side effects in the elderly.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.

The relationship between pain and mood following spinal cord injury

OBJECTIVES

To explore the relationship between pain and mood during spinal cord injury rehabilitation, and to discuss clinical implications to optimize rehabilitation outcomes.

DESIGN

Repeated measures, retrospective cohort study.

SETTING

Tertiary care, spinal cord injury rehabilitation center.

PARTICIPANTS

Patients (N = 509) who completed both Needs Assessment Checklist (NAC) 1 and NAC2 between February 2008 and February 2015.

INTERVENTIONS

Not applicable.

OUTCOME MEASURE

Pain ratings (0-10) and mood scores (0-24) were obtained from the Needs Assessment Checklist (NAC). NAC1 is completed within 4 weeks post-mobilization and NAC2 upon the patient moving to the pre-discharge ward.

RESULTS

There were statistically significant improvements in both pain and mood from NAC1 to NAC2. There were significant correlations between pain and mood at both NAC1 and NAC2 (a decrease in pain was associated with an improvement in mood). Individuals who reported that pain interfered with their rehabilitation had higher pain scores and lower mood scores at both NAC1 and NAC2.

CONCLUSIONS

Pain and mood evidently interact following spinal cord injury, and the nature of this relationship is complex. The current study provides some support for the bidirectional causality hypothesis, suggesting that pain and mood exert an effect upon each other. It is important to address pain and psychological issues early and together in the post-injury phase to optimize rehabilitation outcomes.

sec-Butylpropylacetamide (SPD), a new amide derivative of valproic acid for the treatment of neuropathic and inflammatory pain

Chronic pain is a multifactorial disease comprised of both inflammatory and neuropathic components that affect ∼20% of the world's population. sec-Butylpropylacetamide (SPD) is a novel amide analogue of valproic acid (VPA) previously shown to possess a broad spectrum of anticonvulsant activity. In this study, we defined the pharmacokinetic parameters of SPD in rat and mouse, and then evaluated its antinociceptive potential in neuropathic and acute inflammatory pain models. In the sciatic nerve ligation (SNL) model of neuropathic pain, SPD was equipotent to gabapentin and more potent than its parent compound VPA. SPD also showed either higher or equal potency to VPA in the formalin, carrageenan, and writhing tests of inflammatory pain. SPD showed no effects on compound action potential properties in a sciatic nerve preparation, suggesting that its mechanism of action is distinct from local anesthetics and membrane stabilizing drugs. SPD's activity in both neuropathic and inflammatory pain warrants its development as a potential broad-spectrum anti-nociceptive drug.

Managing Neuropathic Pain in Dogs

Disorders of the somatosensory system such as neuropathic pain are common in people with chronic neurologic and musculoskeletal diseases, yet these conditions remain an underappreciated morbidity in veterinary patients. This is likely because assessment of neuropathic pain in people relies heavily on self-reporting, something our veterinary patients are not able to do. The development of neuropathic pain is a complex phenomenon, and concepts related to it are frequently not addressed in the standard veterinary medical curriculum such that veterinarians may not recognize this as a potential problem in patients. The goals of this review are to discuss basic concepts in the pathophysiology of neuropathic pain, provide definitions for common clinical terms used in association with the condition, and discuss pharmacological treatment options for dogs with neuropathic pain. The development of neuropathic pain involves key mechanisms such as ectopic afferent nerve activity, peripheral sensitization, central sensitization, impaired inhibitory modulation, and pathologic activation of microglia. Treatments aimed at reducing neuropathic pain are targeted at one or more of these mechanisms. Several drugs are commonly used in the veterinary clinical setting to treat neuropathic pain. These include gabapentin, pregabalin, amantadine, and amitriptyline. Proposed mechanisms of action for each drug, and known pharmacokinetic profiles in dogs are discussed. Strong evidence exists in the human literature for the utility of most of these treatments, but clinical veterinary-specific literature is currently limited. Future studies should focus on objective methods to document neuropathic pain and monitor response to therapy in veterinary patients.

Spinal cord injury-induced pain: mechanisms and treatments

Pain is a common consequence of a spinal cord injury (SCI) and has a major impact on quality of life through its impact on physical function, mood and participation in work, recreational and social activities. Several types of pain typically present following SCI with central neuropathic pain being a frequent and difficult to manage occurrence. Despite advances in our understanding of the mechanisms contributing to this type of pain and an increasing number of trials examining treatment efficacy, our ability to relieve neuropathic SCI pain is still very limited. Optimal management relies upon an integrated approach that uses a combination of pharmacological and nonpharmacological options.

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, especially 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.

Impact of an online medical internet site on knowledge and practice of health care providers: a mixed methods study of the Spinal Cord Injury Rehabilitation Evidence project

Background

It is not known whether ongoing access to a broad-based Internet knowledge resource can influence the practice of health care providers. We undertook a study to evaluate the impact of a Web-based knowledge resource on increasing access to evidence and facilitating best practice of health care providers.

Objective

The objective of this study was to evaluate (1) the impact of the Spinal Cord Injury Rehabilitation Evidence (SCIRE) project on access to information for health care providers and researchers and (2) how SCIRE influenced health care providers' management of clients.

Methods

A 4-part mixed methods evaluation was undertaken: (1) monitoring website traffic and utilization using Google Analytics, (2) online survey of users who accessed the SCIRE website, (3) online survey of targeted end-users, that is, rehabilitation health care providers known to work with spinal cord injury (SCI) clients, as well as researchers, and (4) focus groups with health care providers who had previously accessed SCIRE.

Results

The online format allowed the content for a relatively specialized field to have far reach (eg, 26 countries and over 6500 users per month). The website survey and targeted end-user survey confirmed that health care providers, as well as researchers perceived that the website increased their access to SCI evidence. Access to SCIRE not only improved knowledge of SCI evidence but helped inform changes to the health providers’ clinical practice and improved their confidence in treating SCI clients. The SCIRE information directly influenced the health providers’ clinical decision making, in terms of choice of intervention, equipment needs, or assessment tool.

Conclusions

A Web-based knowledge resource may be a relatively inexpensive method to increase access to evidence-based information, increase knowledge of the evidence, inform changes to the health providers’ practice, and influence their clinical decision making.