Barriers and Facilitators to Optimal Neuropathic Pain Management: SCI Consumer, Significant Other, and Health Care Provider Perspectives.

OBJECTIVE: Persistent neuropathic pain is a common and often severe consequence of spinal cord injury (SCI). There is a critical need to better understand how to overcome barriers and promote facilitators to optimal pain management. The present study was designed to identify, from the perspectives of persons living with SCI, their significant others, and SCI health care professionals, the barriers and facilitators to optimal pain management for intense neuropathic pain. DESIGN: Qualitative interviews. SETTING: University laboratory. SUBJECTS: People with SCI who had experienced intense neuropathic pain for a minimum of a year (N = 15), their significant others (N = 15), and SCI health care providers (N = 15). METHODS: Qualitative interviews were recorded, transcribed, and analyzed based on grounded theory using ATLAS.ti software. RESULTS: Inadequate access to care, information, or pain management expertise were frequently perceived barriers to optimal pain management across all three groups. Another major barrier was SCI stakeholders' concerns regarding the risks of adverse effects and addiction to pain medication. Facilitators included having a better understanding of pain and available treatment options, effective patient-provider communication, resilience, and access to nonpharmacological treatment options. CONCLUSIONS: Managing intense neuropathic pain poses significant challenges after SCI. SCI stakeholders felt that accessible treatment options were limited and primarily focused on pain medications with minimal benefit but with significant risks for addiction and adverse effects. Actionable facilitators to optimal pain management after SCI include education regarding neuropathic pain and treatment options for all stakeholders, better communication regarding neuropathic pain among stakeholders, and improved patient access to nonpharmacological treatment options.

Utility of the Neuropathic Pain Symptom Inventory in people with spinal cord injury.

STUDY DESIGN: Cohort/psychometric study OBJECTIVES: The primary objective was to determine the psychometric properties and the utility of the Neuropathic Pain Symptom Inventory (NPSI) in subgrouping people with moderate to severe neuropathic pain after spinal cord injury (SCI). SETTING: University-based laboratory in Miami, FL USA. METHODS: Seventy-two people with chronic SCI and neuropathic pain were included in this study. The NPSI, Numeric Rating Scale (NRS), Multidimensional Pain Inventory pain severity and perceived support subscales (MPI-PS and MPI-S, respectively), and the Coping Strategies Questionnaire were administered. The NPSI was administered twice, with a 2-4-week period between measurement sessions. RESULTS: The NPSI total score demonstrated good internal consistency with a Cronbach's alpha of 0.70. The test-retest reliability (intraclass correlations) ranged from 0.65 to 0.73 for the NPSI subscores and 0.79 for the total NPSI score. Further, construct validity was supported by moderate and significant positive correlations with the pain intensity NRS and pain severity subscale of the MPI (MPI-PS) (r > 0.40). Cluster analysis of factor scores derived from NPSI subscales, NRS, and MPI-PS scores revealed three distinct subgroups: (1) low-moderate, (2) moderate, and (3) high pain symptom severity with mean NPSI sum scores of 7.1, 17.5, and 33.8, respectively. CONCLUSION: The NPSI demonstrated good psychometric properties in people with neuropathic pain after SCI. Moreover, it has utility for establishing pain symptom phenotypes.

Neuropsychological Function in Traumatic Brain Injury and the Influence of Chronic Pain.

Cognitive dysfunction, pain, and psychological morbidity all present unique challenges to those living with traumatic brain injury (TBI). In this study we examined (a) the impact of pain across domains of attention, memory, and executive function, and (b) the relationships between pain and depression, anxiety, and post-traumatic stress disorder (PTSD) in persons with chronic TBI. Our sample included 86 participants with a TBI and chronic pain (n = 26), patients with TBI and no chronic pain (n = 23), and a pain-free control group without TBI (n = 37). Participants visited the laboratory and completed a comprehensive battery of neuropsychological tests as part of a structured interview. Multivariate analysis of covariance using education as a covariate, failed to detect a significant group difference for neuropsychological composite scores of attention, memory, and executive function (p = .165). A follow-up analysis using multiple one-way analysis of variance (ANOVA) was conducted for individual measures of executive function. Post-hoc testing indicated that those in both TBI groups preformed significantly worse on measures of semantic fluency when compared to controls (p < 0.001, ηρ2 = .16). Additionally, multiple ANOVAs indicated that those with TBI and pain scored significantly worse across all psychological assessments (p < .001). We also found significant associations between measures of pain and most psychological symptoms. A follow-up stepwise linear regression among those in the TBI pain group indicated that post concussive complaints, pain severity, and neuropathic pain symptoms differentially contributed to symptoms of depression, anxiety, and PTSD. These findings suggest deficits in verbal fluency among those living with chronic TBI, with results also reinforcing the multidimensional nature of pain and its psychological significance in this population.

Multidimensional pain phenotypes after Traumatic Brain Injury.

More than 50% of individuals develop chronic pain following traumatic brain injury (TBI). Research suggests that a significant portion of post-TBI chronic pain conditions is neuropathic in nature, yet the relationship between neuropathic pain, psychological distress, and somatosensory function following TBI is not fully understood. This study evaluated neuropathic pain symptoms, psychological and somatosensory function, and psychosocial factors in individuals with TBI (TBI, N = 38). A two-step cluster analysis was used to identify phenotypes based on the Neuropathic Pain Symptom Inventory and Beck's Anxiety Inventory scores. Phenotypes were then compared on pain characteristics, psychological and somatosensory function, and psychosocial factors. Our analyses resulted in two different neuropathic pain phenotypes: (1) Moderate neuropathic pain severity and anxiety scores (MNP-AS, N = 11); and (2) mild or no neuropathic pain symptoms and anxiety scores (LNP-AS, N = 27). Furthermore, the MNP-AS group exhibited greater depression, PTSD, pain severity, and affective distress scores than the LNP-AS group. In addition, thermal somatosensory function (difference between thermal pain and perception thresholds) was significantly lower in the MNP-AS compared to the LNP-AS group. Our findings suggest that neuropathic pain symptoms are relatively common after TBI and are not only associated with greater psychosocial distress but also with abnormal function of central pain processing pathways.