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Shoup JA, Welter J, Binswanger IA, Hess F, Dullenkopf A, Coker J, Berliner J. Spinal cord injury and prescribed opioids for pain: a scoping review. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1138-1152. [PMID: 37280072 DOI: 10.1093/pm/pnad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/05/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Spinal cord injury (SCI) is a life-altering neurological condition affecting physical and psycho-social functioning and associated high rates of pain. Thus, individuals with SCI may be more likely to be exposed to prescription opioids. A scoping review was conducted to synthesize published research findings on post-acute SCI and prescription opioid use for pain, identify literature gaps, and propose recommendations for future research. METHODS We searched 6 electronic bibliographic databases (PubMed [MEDLINE], Ovid [MEDLINE], EMBASE, Cochrane Library, CINAHL, PsychNET) for articles published from 2014 through 2021. Terms for "spinal cord injury" and "prescription opioid use" were used. Included articles were in English and peer reviewed. Data were extracted using an electronic database by 2 independent reviewers. Opioid use risk factors for chronic SCI were identified and a gap analysis was performed. RESULTS Of the 16 articles included in the scoping review, a majority were conducted in the United States (n = 9). Most articles lacked information on income (87.5%), ethnicity (87.5%), and race (75%). Prescription opioid use ranged from 35% to 64% in articles reporting this information (n = 7 articles, n = 3675 participants). Identified risk factors for opioid use included middle age, lower income, osteoarthritis diagnosis, prior opioid use, and lower-level spinal injury. Limited reporting of diversity in study populations, absence of risk of polypharmacy, and limited high quality methodology were identified gaps. CONCLUSIONS Future research should report data on prescription opioid use in SCI populations, with additional demographics such as race, ethnicity, and income, given their importance to risk outcomes.
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Affiliation(s)
- Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO 80014, United States
- School of Public Affairs, University of Colorado Denver, Denver, CO 80204, United States
| | - JoEllen Welter
- Department of Orthopedic Surgery and Traumatology, Spital Thurgau, 8501 Frauenfeld, Switzerland
- Institute for Anesthesia and Intensive Care Medicine, Spital Thurgau, 8501 Frauenfeld, Switzerland
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO 80014, United States
- Colorado Permanente Medical Group, Denver, CO 80218, United States
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO 80045, United States
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA 91101, United States
| | - Florian Hess
- Department of Orthopedic Surgery and Traumatology, Spital Thurgau, 8501 Frauenfeld, Switzerland
| | - Alexander Dullenkopf
- Institute for Anesthesia and Intensive Care Medicine, Spital Thurgau, 8501 Frauenfeld, Switzerland
| | - Jennifer Coker
- Craig Hospital Research Department, Craig Hospital, Englewood, CO 80113, United States
| | - Jeffrey Berliner
- Craig Hospital Research Department, Craig Hospital, Englewood, CO 80113, United States
- CNS Medical Group, Craig Hospital, Englewood, CO 80113, United States
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Furlan JC, Loh E, Boulos MI. The potential effects of untreated sleep-related breathing disorders on neuropathic pain, spasticity, and cardiovascular dysfunction following spinal cord injury: A cross-sectional prospective study protocol. PLoS One 2023; 18:e0282860. [PMID: 37130111 PMCID: PMC10153696 DOI: 10.1371/journal.pone.0282860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 05/03/2023] Open
Abstract
INTRODUCTION Sleep-related breathing disorders (SRBDs), neuropathic pain, spasticity and cardiovascular autonomic dysfunction are common after spinal cord injury (SCI). Prior studies suggest that systemic inflammation following SCI may be implicated in the development of neuropathic pain, spasticity and cardiovascular dysfunction. Given that SRBDs also cause a systemic inflammatory response, we hypothesized that individuals with SCI who develop more severe SRBDs would experience more intense neuropathic pain, more severe spasticity and more significant cardiovascular autonomic dysfunction. METHODS This cross-sectional prospective study will explore the previously understudied hypothesis that SRBDs are associated with increased neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in adult individuals with low-cervical/high-thoracic (injury level at C5 to T6), complete/incomplete (ASIA Impairment Scale A, B, C or D) SCI. DISCUSSION To our knowledge, no prior study has addressed this clinically relevant question on whether the degree of SRBDs affects the intensity of neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in individuals with SCI. We anticipate that the results of this original study will provide key information for a future clinical trial on the use of continuous positive airway pressure (CPAP) therapy for moderate-to-severe SRBDs, which may better control neuropathic pain, spasticity, and cardiovascular autonomic dysfunction among individuals with SCI. TRIAL REGISTRATION The research protocol for this study was registered in the ClinicalTrials.gov website (NCT05687097). https://clinicaltrials.gov/ct2/show/NCT05687097.
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Affiliation(s)
- Julio Cesar Furlan
- Toronto Rehabilitation Institute, Lyndhurst Centre, University Health Network, Toronto, Ontario, Canada
- KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eldon Loh
- Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, ON, Canada
- Parkwood Institute Research, Lawson Health Research Institute, London, ON, Canada
| | - Mark Iskander Boulos
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute and Sunnybrook Health Sciences Centre, Hurvitz Brain Sciences Research Program, Toronto, ON, Canada
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, ON, Canada
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3
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Karran EL, Wiles LK, Wilson DJ, Moseley GL. Best practice care for persistent pain in adults with spinal cord injuries: a systematic review and narrative synthesis of clinical practice guideline recommendations. Disabil Rehabil 2022:1-10. [DOI: 10.1080/09638288.2022.2093998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Emma L. Karran
- Innovation, Implementation and Clinical Translation (IIMPACT) in Health, University of South Australia, Adelaide, Australia
| | - Louise K. Wiles
- Innovation, Implementation and Clinical Translation (IIMPACT) in Health, University of South Australia, Adelaide, Australia
| | - Dianne J. Wilson
- Innovation, Implementation and Clinical Translation (IIMPACT) in Health, University of South Australia, Adelaide, Australia
| | - G. Lorimer Moseley
- Innovation, Implementation and Clinical Translation (IIMPACT) in Health, University of South Australia, Adelaide, Australia
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The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update. Spinal Cord 2022; 60:548-566. [PMID: 35124700 PMCID: PMC9209331 DOI: 10.1038/s41393-021-00744-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 12/23/2022]
Abstract
STUDY DESIGN Clinical practice guidelines. OBJECTIVES The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI). SETTING The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada. METHODS The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations. RESULTS The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made. CONCLUSIONS The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice.
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Bragge P, Allison DJ, Mehta S, Guy S, Loh E. A pilot living clinical practice guidelines approach was feasible and acceptable to guideline panel members. J Clin Epidemiol 2021; 143:22-29. [PMID: 34856368 DOI: 10.1016/j.jclinepi.2021.11.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/18/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Clinical practice guidelines (CPGs) help to translate best available evidence into clinical practice but can be challenging to keep current due to their resource intensive nature. A "living" process that is used to continually update CPGs may therefore be of value. STUDY DESIGN AND SETTING This pilot study assesses the development of a living CPG protocol based on the CanPainSCI CPG. Two "living CPG" update searches were performed; resource costs and acceptability were assessed by a research team across Australia and Canada RESULTS: Two updates were completed over 3 years. Literature searches and data extraction were completed by trainees on 119 and 58 papers. Eight papers were included and reviewed by 14 expert panel members. Resource usage included a total 43 hours of screening by trainees at $2,356 (USD), 24 hours of expert panel review at $3,141 (USD) and 30 hours of project management at $3,241 (USD). Reviewers were generally satisfied with the process. All reviewers agreed that incorporating a living guidelines approach would be useful. CONCLUSION This paper outlines the process of maintaining a CPG through a living guideline process and provides resource costs and acceptability data which may aid stakeholders in the development of future CPGs.
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Affiliation(s)
- Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Clayton, VIC 3800, Australia.
| | - David J Allison
- Parkwood Institute Research, Lawson Health Research Institute, London, Ontario, Canada
| | - Swati Mehta
- Parkwood Institute Research, Lawson Health Research Institute, London, Ontario, Canada
| | - Stacey Guy
- Ontario Centers for Learning, Research and Innovation, Baycrest Health Sciences, Toronto, Ontario, Canada
| | - Eldon Loh
- Parkwood Institute Research, Lawson Health Research Institute, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Western University, London, Ontario, Canada
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Clares JWB, Guedes MVC, Freitas MCD. Construction of nursing diagnoses for people with spinal cord injury in rehabilitation. Rev Esc Enferm USP 2021; 55:e03750. [PMID: 34346966 DOI: 10.1590/s1980-220x2020038403750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/16/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To construct nursing diagnosis statements of the International Classification for Nursing Practice (ICNP®) for the spinal cord rehabilitation specialty based on the Callista Roy Adaptation Model. METHOD Descriptive study developed in sequential steps of identification and cross-mapping of terms relevant to care with the health priority, construction and cross-mapping of nursing diagnosis statements based on the ICNP®, and categorization of diagnoses according to adaptive modes. RESULTS Ninety-two statements of nursing diagnoses were developed, of which 66 were classified in the Physiological Mode, 12 in Functional Role Mode, 10 in Self-Concept Mode and four in Interdependence Mode. CONCLUSION The nursing diagnoses developed portray focuses of attention for nursing care to people with spinal cord injury in rehabilitation and contribute to the direction of nursing care actions in a systematic, individualized and resolutive way.
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Affiliation(s)
| | - Maria Vilaní Cavalcante Guedes
- Universidade Estadual do Ceará, Centro de Ciências da Saúde, Programa de Pós-Graduação Cuidados Clínicos em Enfermagem e Saúde, Fortaleza, CE, Brasil
| | - Maria Célia de Freitas
- Universidade Estadual do Ceará, Centro de Ciências da Saúde, Programa de Pós-Graduação Cuidados Clínicos em Enfermagem e Saúde, Fortaleza, CE, Brasil
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Franz S, Schulz B, Wang H, Gottschalk S, Grüter F, Friedrich J, Glaesener JJ, Bock F, Schott C, Müller R, Schultes K, Landmann G, Gerner HJ, Dietz V, Treede RD, Weidner N. Management of pain in individuals with spinal cord injury: Guideline of the German-Speaking Medical Society for Spinal Cord Injury. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2019; 17:Doc05. [PMID: 31354397 PMCID: PMC6637293 DOI: 10.3205/000271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Indexed: 12/19/2022]
Abstract
Introduction: Pain is a prominent complication in spinal cord injury (SCI). It can either occur as a direct or as an indirect consequence of SCI and it often heavily influences the quality of life of affected individuals. In SCI, nociceptive and neuropathic pain can equally emerge at the same time above or below the level of injury. Thus, classification and grading of pain is frequently difficult. Effective treatment of SCI-related pain in general and of neuropathic pain in particular is challenging. Current treatment options are sparse and their evidence is considered to be limited. Considering these aspects, a clinical practice guideline was developed as basis for an optimized, comprehensive and standardized pain management in SCI-related pain. Methods: The German-Speaking Medical Society for Spinal Cord Injury (Deutschsprachige Medizinische Gesellschaft für Paraplegiologie – DMGP) developed a clinical practice guideline that received consensus from seven further German-speaking medical societies and one patient organization. The evidence base from clinical trials and meta-analyses was summarized and subjected to a structured consensus-process in accordance with the regulations of the Association of Scientific Medical Societies in Germany (AWMF) and the methodological requirements of the “German instrument for methodological guideline appraisal”. Results: This consensus-based guideline (S2k classification according to the AWMF guidance manual and rules) resulted in seven on-topic statements and 17 specific recommendations relevant to the classification, assessment and therapy of pain directly or indirectly caused by SCI. Recommended therapeutic approaches comprise pharmacological (e.g. nonsteroidal anti-inflammatory drugs or anticonvulsants) and non-pharmacological (e.g. physical activity or psychotherapeutic techniques) strategies for both nociceptive and neuropathic pain. Discussion: Assessment of SCI-related pain is standardized and respective methods in terms of examination, classification and grading of pain are already in use and validated in German language. In contrast, valid, evidence-based and efficient therapeutic options are limited and ask for further clinical studies, ideally randomized controlled trials and meta-analyses.
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Affiliation(s)
- Steffen Franz
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Barbara Schulz
- BG Klinikum Bergmannstrost, Abteilung Medizinische Psychologie, Spezielle Traumatherapie (DeGPT), Hypnotherapie und Hypnose (DGH), Halle, Germany
| | - Haili Wang
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Sabine Gottschalk
- Zentralklinik Bad Berka GmbH, Querschnittgelähmten-Zentrum/Klinik für Paraplegiologie und Neuro-Urologie, Bad Berka, Germany
| | - Florian Grüter
- Kliniken Beelitz GmbH, Neurologische Rehabilitationsklinik, Beelitz-Heilstätten, Germany
| | | | | | | | - Cordelia Schott
- Orthopädische Privatpraxis Schott (OPS), Im Medizinischen Zentrum Essen, Germany
| | | | - Kevin Schultes
- Fördergemeinschaft der Querschnittgelähmten in Deutschland e.V., Lobbach, Germany
| | - Gunther Landmann
- Center for Pain Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Hans Jürgen Gerner
- Fördergemeinschaft der Querschnittgelähmten in Deutschland e.V., Lobbach, Germany
| | - Volker Dietz
- Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland
| | - Rolf-Detlef Treede
- Chair of Neurophysiology, Centre of Biomedicine and Medical Technology Mannheim, Heidelberg University, Mannheim, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
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8
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Hong Y, Geraci M, Turk MA, Love BL, McDermott SW. Opioid Prescription Patterns for Adults With Longstanding Disability and Inflammatory Conditions Compared to Other Users, Using a Nationally Representative Sample. Arch Phys Med Rehabil 2019; 100:86-94.e2. [DOI: 10.1016/j.apmr.2018.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/26/2018] [Accepted: 06/30/2018] [Indexed: 02/08/2023]
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9
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Gong N, Park J, Luo ZD. Injury-induced maladaptation and dysregulation of calcium channel α 2 δ subunit proteins and its contribution to neuropathic pain development. Br J Pharmacol 2018; 175:2231-2243. [PMID: 28646556 PMCID: PMC5980513 DOI: 10.1111/bph.13930] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/05/2017] [Accepted: 06/12/2017] [Indexed: 01/12/2023] Open
Abstract
Voltage-gated calcium channels (VGCCs) play important roles in physiological functions including the modulation of neurotransmitter release, neuronal network activities, intracellular signalling pathways and gene expression. Some pathological conditions, including nerve injuries, can cause the dysregulation of VGCCs and their subunits. This in turn can lead to a functional maladaptation of VGCCs and their subunits, which can contribute to the development of disorders such as pain sensations. This review has summarized recent findings related to maladaptive changes in the dysregulated VGCC α2 δ1 subunit (Cav α2 δ1 ) with a focus on exploring the mechanisms underlying the contribution of Cav α2 δ1 to pain signal transduction. At least under neuropathic pain conditions, the dysregulated Cav α2 δ1 can modulate VGCC functions as well as other plasticity changes. The latter includes abnormal excitatory synaptogenesis resulting from its interactions with injury-induced extracellular matrix glycoprotein molecule thrombospondins, which is independent of the VGCC functions. Blocking Cav α2 δ1 with gabapentinoids can reverse neuropathic pain significantly with relatively mild side effects, but only in a small population of neuropathic pain patients due to reasons yet to be explored. There are emerging data suggesting that early preventive treatment with gabapentinoids can prevent aberrant excitatory synapse formation and the development of chronic pain. If these findings are confirmed clinically, this could be an attractive approach for neuropathic pain management. LINKED ARTICLES This article is part of a themed section on Recent Advances in Targeting Ion Channels to Treat Chronic Pain. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.12/issuetoc.
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Affiliation(s)
- Nian Gong
- Department of Anesthesiology & Perioperative CareSchool of Medicine, University of California IrvineIrvineCAUSA
| | - John Park
- Department of Pharmacology, School of MedicineUniversity of California IrvineIrvineCAUSA
| | - Z David Luo
- Department of Anesthesiology & Perioperative CareSchool of Medicine, University of California IrvineIrvineCAUSA
- Department of Pharmacology, School of MedicineUniversity of California IrvineIrvineCAUSA
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10
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Landmann G, Chang EC, Dumat W, Lutz A, Müller R, Scheel-Sailer A, Schwerzmann K, Sigajew N, Ljutow A. [Pain in patients with paraplegia]. Schmerz 2017; 31:527-545. [PMID: 28940094 DOI: 10.1007/s00482-017-0250-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chronic pain is one of the most reported health problems in patients suffering from spinal cord injuries and is described by the patients as one of the most burdensome sequelae of paraplegia. Various types of pain, such as nociceptive, neuropathic and other types of pain can occur. In addition, multiple pathophysiological mechanisms based on the biopsychosocial pain model play a role in the origins of the pain. These aspects necessitate a multimodal pain management approach in this patient group. This article presents an overview of the occurrence, importance and pathophysiology of chronic pain following spinal cord injury as well as diagnostic and therapeutic approaches.
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Affiliation(s)
- G Landmann
- Zentrum für Schmerzmedizin, Schweizer Paraplegiker-Zentrum, 6207, Nottwil, Guido-A.-Zäch-Str. 1, Schweiz.
| | - E-C Chang
- Zentrum für Schmerzmedizin, Schweizer Paraplegiker-Zentrum, 6207, Nottwil, Guido-A.-Zäch-Str. 1, Schweiz
| | - W Dumat
- Wenckebach-Klinikum, Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Berlin, Deutschland
| | - A Lutz
- Ergotherapie, Schweizer Paraplegiker-Zentrum, Nottwil, Schweiz
| | - R Müller
- Schweizer Paraplegiker-Forschung, Nottwil, Schweiz.,Department Gesundheitswissenschaften und Gesundheitspolitik, Universität Luzern, Luzern, Schweiz
| | - A Scheel-Sailer
- Department Gesundheitswissenschaften und Gesundheitspolitik, Universität Luzern, Luzern, Schweiz.,Forschung Rehabilitation Qualitätsmanagement, Schweizer Paraplegiker-Zentrum, Nottwil, Schweiz
| | - K Schwerzmann
- Zentrum für Schmerzmedizin, Schweizer Paraplegiker-Zentrum, 6207, Nottwil, Guido-A.-Zäch-Str. 1, Schweiz
| | - N Sigajew
- Zentrum für Schmerzmedizin, Schweizer Paraplegiker-Zentrum, 6207, Nottwil, Guido-A.-Zäch-Str. 1, Schweiz
| | - A Ljutow
- Zentrum für Schmerzmedizin, Schweizer Paraplegiker-Zentrum, 6207, Nottwil, Guido-A.-Zäch-Str. 1, Schweiz
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Taneja A, Della Pasqua O, Danhof M. Challenges in translational drug research in neuropathic and inflammatory pain: the prerequisites for a new paradigm. Eur J Clin Pharmacol 2017; 73:1219-1236. [PMID: 28894907 PMCID: PMC5599481 DOI: 10.1007/s00228-017-2301-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/03/2017] [Indexed: 12/21/2022]
Abstract
AIM Despite an improved understanding of the molecular mechanisms of nociception, existing analgesic drugs remain limited in terms of efficacy in chronic conditions, such as neuropathic pain. Here, we explore the underlying pathophysiological mechanisms of neuropathic and inflammatory pain and discuss the prerequisites and opportunities to reduce attrition and high-failure rate in the development of analgesic drugs. METHODS A literature search was performed on preclinical and clinical publications aimed at the evaluation of analgesic compounds using MESH terms in PubMed. Publications were selected, which focused on (1) disease mechanisms leading to chronic/neuropathic pain and (2) druggable targets which are currently under evaluation in drug development. Attention was also given to the role of biomarkers and pharmacokinetic-pharmacodynamic modelling. RESULTS Multiple mechanisms act concurrently to produce pain, which is a non-specific manifestation of underlying nociceptive pathways. Whereas these manifestations can be divided into neuropathic and inflammatory pain, it is now clear that inflammatory mechanisms are a common trigger for both types of pain. This has implications for drug development, as the assessment of drug effects in experimental models of neuropathic and chronic pain is driven by overt behavioural measures. By contrast, the use of mechanistic biomarkers in inflammatory pain has provided the pharmacological basis for dose selection and evaluation of non-steroidal anti-inflammatory drugs (NSAIDs). CONCLUSION A different paradigm is required for the identification of relevant targets and candidate molecules whereby pain is coupled to the cause of sensorial signal processing dysfunction rather than clinical symptoms. Biomarkers which enable the characterisation of drug binding and target activity are needed for a more robust dose rationale in early clinical development. Such an approach may be facilitated by quantitative clinical pharmacology and evolving technologies in brain imaging, allowing accurate assessment of target engagement, and prediction of treatment effects before embarking on large clinical trials.
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Affiliation(s)
- A Taneja
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - O Della Pasqua
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Uxbridge, UK.,Clinical Pharmacology & Therapeutics Group, University College London, London, UK
| | - M Danhof
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
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12
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Reck TA, Landmann G. Successful spinal cord stimulation for neuropathic below-level spinal cord injury pain following complete paraplegia: a case report. Spinal Cord Ser Cases 2017; 3:17049. [PMID: 28808583 PMCID: PMC5550928 DOI: 10.1038/scsandc.2017.49] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/28/2017] [Accepted: 07/04/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Neuropathic pain is common in patients with spinal cord injury (SCI) and often difficult to treat. We report a case where epidural spinal cord stimulation (SCS) below the level of injury has been successfully applied in a patient with a complete spinal cord lesion. CASE PRESENTATION A 53-year-old female presented with neuropathic below-level SCI pain of both lower legs and feet due to complete SCI below T5. Time and pain duration since injury was 2 years. Pain intensity was reported on numeric rating scale with an average of 7/10 (0 meaning no pain, 10 meaning the worst imaginable pain), but also with about 8-10 pain attacks during the day with an intensity of 9/10, which lasted between some minutes and half an hour. SCS was applied below the level of injury at-level T11-L1. After a successful 2 weeks testing period the pulse generator has been implanted permanently with a burst-stimulation pattern. The average pain was reduced to a bearable intensity of 4/10, in addition attacks could be reduced both in frequency and in intensity. This effects lasted for at least three months of follow-up. DISCUSSION Even in case of complete SCI, SCS might be effective. Mechanisms of pain relief remain unclear. A modulation of suggested residual spinothalamic tract function may play a role. Further investigation has to be carried out to support this theory.
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Affiliation(s)
- Tim A Reck
- Centre for Pain Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Gunther Landmann
- Centre for Pain Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
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13
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Loh E, Guy SD, Craven BC, Guilcher S, Hayes KC, Jeji T, Joshi P, Kras-Dupuis A, Laramée MT, Lee J, Mehta S, Noonan VK, Mings EJ, Salter M, Short C, Bassett-Spiers K, White B, Wolfe DL, Xia N. Advancing research and clinical care in the management of neuropathic pain after spinal cord injury: Key findings from a Canadian summit. Can J Pain 2017; 1:183-190. [PMID: 35005353 PMCID: PMC8730656 DOI: 10.1080/24740527.2017.1385370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI. Aims: A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI. Methods: In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action. Results: A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame. Conclusion: A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors.
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Affiliation(s)
- Eldon Loh
- Parkwood Institute Research, St. Joseph’s Health Care, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Stacey D. Guy
- Parkwood Institute Research, St. Joseph’s Health Care, London, Ontario, Canada
| | - B. Cathy Craven
- Toronto Rehabilitation Institute, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Sara Guilcher
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Keith C. Hayes
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | - Tara Jeji
- Ontario Neurotrauma Foundation, Toronto, Ontario, Canada
| | - Phalgun Joshi
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Anna Kras-Dupuis
- Parkwood Institute Research, St. Joseph’s Health Care, London, Ontario, Canada
| | - Marie-Thérèse Laramée
- Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l’Île-de-Montréal and Centre de Recherche Interdisciplinaire en Réadaptation, Montréal, Quebec, Canada
| | - Joseph Lee
- The Centre for Family Medicine, Kitchener, Ontario, Canada
| | - Swati Mehta
- Parkwood Institute Research, St. Joseph’s Health Care, London, Ontario, Canada
| | | | | | - Michael Salter
- The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christine Short
- Department of Medicine, Division of Physical Medicine and Rehabilitation Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Rehabilitation Centre, Halifax, Nova Scotia, Canada
| | | | - Barry White
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Dalton L. Wolfe
- Parkwood Institute Research, St. Joseph’s Health Care, London, Ontario, Canada
| | - Nancy Xia
- SCI Ontario, Toronto, Ontario, Canada
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Charbonneau R. Standardizing the evaluation and management of neuropathic pain following spinal cord injury. CMAJ 2016; 189:E48-E49. [PMID: 27956396 DOI: 10.1503/cmaj.161036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Rebecca Charbonneau
- Glenrose Rehabilitation Hospital and University of Alberta, Division of Physical Medicine and Rehabilitation, Edmonton, Alta.
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