A COM-B and Theoretical Domains Framework Mapping of the Barriers and Facilitators to Effective Communication and Help-Seeking Among People With, or Seeking a Diagnosis Of, Endometriosis.

Endometriosis is a chronic condition in which tissue resembling the endometrium grows outside the womb, causing severe chronic pain. People with endometriosis report difficulty in help-seeking and communicating with healthcare professionals, contributing to diagnosis delays and ineffective management. The present study aimed to identify barriers and facilitators to effective communication using the Theoretical Domains Framework (TDF) and COM-B model to inform behavior change intervention development. This study was a qualitative semi-structured interview and open-ended survey design. Thematic Analysis was utilized to identify barriers and facilitators to effective communication which were mapped to the TDF and COM-B model. Four women aged 25 to 44 with a formal diagnosis of endometriosis participated in interviews. Thirty-three participants, aged 20-48 years, participated in the online survey, 21 of whom had a diagnosis of endometriosis (12 were currently seeking diagnosis). Five COM-B domains were identified: reflective motivation, social and physical opportunity, physical and psychological capability. Ten TDF domains were reflected in concerns surrounding dismissal, disempowerment, social norms, beliefs about consequences, cognitive resources, reinforcement, and environmental context and resources, among others. This is the first study to identify barriers and facilitators of effective communication and help-seeking in light of established behavioral change theory and frameworks for comprehensive intervention design. This provides a comprehensive explanation of challenges in help-seeking for endometriosis and represents the first step in the development of complex interventions to improve help-seeking and communication for people with endometriosis. Interventions targeting salient barriers will have greater potential to change behavior and improve outcomes.

'We're all in the same boat': An Interpretative Phenomenological Analysis study of experiences of being an 'expert' during patient and public involvement within Child and Adolescent Mental Health Services (CAMHS).

BACKGROUND: Patient and Public involvement (PPI) has rapidly evolved into a key component in shaping the delivery of health services. However, little is known about what it is like to participate in involvement procedures that include representatives of multiple groups and in the context of developing new interventions for Child and Adolescent Mental Health Services (CAMHS). OBJECTIVE: This study explored participants' experiences of PPI, following attending a 'consensus conference', during which their views were sought in relation to the development of a proposed staff-based intervention and key questions about its design and implementation. DESIGN: Qualitative, semi-structured interview study. SETTING AND PARTICIPANTS: Six participants, including service users and various frontline clinical staff team members, who had experience of CAMHS were present at the consensus conference and then asked about their experiences of being involved via semi-structured interviews. The data were analysed using Interpretative Phenomenological Analysis (IPA). Young people, carers and frontline staff have been involved in the design and implementation throughout the broader programme of work of which this study forms part, although these groups were not directly involved in the design and implementation of this paper. RESULTS: Three key narratives were present: (a) Previous Experiences Driving Expectations, (b) 'We are all in the same boat' and (c) The Realization of Multiple Identities. The results suggest that PPI involvement is a complex process that may be driven by positive/negative expectations, but that individuals value learning about others and recognizing different perspectives while reaching shared goals in improving services. DISCUSSION AND CONCLUSION: This study demonstrates the complexity of experience that service users and clinical staff face when engaging in involvement activities in CAMHS. The findings demonstrate the value in engaging multiple stakeholder groups while also highlighting the importance of proper consideration of the procedures involved and facilitators of engagement.

Mindfulness for pain, depression, anxiety, and quality of life in people with spinal cord injury: a systematic review.

BACKGROUND: Populations with reduced sensory and motor function, such as spinal cord injury (SCI) are at increased risk of depression, anxiety, pain, and poorer quality of life (QoL). Mindfulness-Based Interventions (MBIs) have been developed with the aim of improving outcomes for people with SCI. To understand the value of MBIs, a systematic review was conducted pertaining to the use of MBIs, and interventions including elements of mindfulness, with people with SCI. METHODS: Databases were reviewed from 1996 to October 2018 (updated January 2020). Eligibility criteria included the assessment of at least one of the common secondary consequences of SCI (i.e. risk of depression, anxiety, pain, and QoL), describe the use of mindfulness training as a component part of an intervention, or as the whole intervention. The Cochrane Collaboration Risk of Bias and The Effective Public Health Practice Project Quality Assessment Tools were utilised for quality appraisals. Two assessors appraised the studies and demonstrated good agreement (Cohen's k = .848, p < .001). RESULTS: Five papers met the inclusion criteria, and demonstrated a range of results of interventions delivered individually, in a group format, in person, and online. Only one study reported significant reductions in pain-related outcomes (with moderate effect sizes), with the remaining studies (n = 4) demonstrating no change. Four studies described reductions in depressive symptoms and three reported reductions in anxiety. Despite the importance of good QoL as a goal for people with SCI, few studies (n = 2) assessed this as an outcome with no improvements reported. Study quality ranged from high to low/weak. CONCLUSIONS: The findings in this review provide mixed support for the use of mindfulness to improve outcomes after SCI. In particular, findings indicate that mindfulness may be particularly effective for improving symptoms of depression and anxiety. This review highlights the requirement for more rigorous, high-quality research, particularly larger randomised-controlled trials with long-term follow-up, in this area. The small number of studies included in the present review mean that conclusions drawn are preliminary and thus reflects the paucity of the research in the area to date.

Depression in partner caregivers of people with neurological conditions; associations with self-compassion and quality of life.

Objectives: Informal caregivers are vulnerable to poor mental health and quality of life (QoL). Self-compassion may protect against this. This study investigated depression and QoL in partner caregivers of people with a long-term or neurological condition (e.g. dementia or spinal cord injury) and explored the extent to which QoL and self-compassion are predictive of depression.Design: A cross-sectional, questionnaire design.Methods: Participants were recruited from charities and support groups. Partner caregivers (N = 57) completed assessments of depression, QoL, and self-compassion.Results: Over half (61.8%) of caregivers experienced at least mild symptoms of depression, illustrating high prevalence among caregivers compared with the general population. Overall QoL was poor compared with non-caregivers. QoL was poorest in the physical domain (M = 51.9, SD = 10.1) and highest in the environmental domain (M = 64.9, SD = 15.8). Both self-compassion and QoL were significant predictors of depression (p < 0.05), explaining 48.8% of the variance. Hours spent providing care was also significantly predictive of depression (p < 0.05).Conclusion: Self-compassion and QoL may be important targets for supportive interventions for this population. This study underscores the importance of developing supportive interventions for informal partner caregivers, and developing self-compassion in these.

Efficacy of Internet-Delivered Mindfulness for Improving Depression in Caregivers of People With Spinal Cord Injuries and Chronic Neuropathic Pain: A Randomized Controlled Feasibility Trial.

OBJECTIVES: To explore the feasibility and efficacy of web-based mindfulness training for carers of people with spinal cord injury (SCI). DESIGN: Randomized controlled feasibility study with 3-month follow-up. SETTING: Community setting. PARTICIPANTS: Spouses or family caregivers (N=55) of people with SCI and chronic neuropathic pain were recruited via the direct care team and advertisements. Participants were older than 18 years (no upper age limit), with Internet access for the duration of the study. Participants were randomly allocated to an 8-week online mindfulness training intervention (n=28), or to receive 8 weeks of psychoeducational materials on SCI and chronic pain (n=27). INTERVENTIONS: An established web-based, mindfulness training course was delivered over 8 weeks. Participants completed 10 minutes of mindfulness practices, twice per day, 6 days per week, totaling 960 minutes. The control group received a weekly e-mail with psychoeducational materials (based on the established elements) on SCI and pain for 8 weeks. MAIN OUTCOME MEASURE: Depression severity. RESULTS: Mindfulness reduced depression severity more than psychoeducation at T2 (mean difference= -.891; 95% confidence interval,-1.48 to -.30) and T3 (mean difference=-1.96; 95% confidence interval, -2.94 to -.97). Mindfulness training also reduced anxiety at T2 (mean difference=-.888; 95% confidence interval, -1.40 to -.38) and T3 (mean difference=-2.44; 95% confidence interval, -3.20 to -1.69). CONCLUSIONS: Results indicate that Internet-delivered mindfulness training offers unique benefits and is viable for caregivers of people with SCI and chronic neuropathic pain. Further work should explore the feasibility of combined education and mindfulness training incorporating both patient and caregiver, for optimum benefit.

Internet-delivered mindfulness for people with depression and chronic pain following spinal cord injury: a randomized, controlled feasibility trial.

STUDY DESIGN: Between-subjects, randomized controlled feasibility study. OBJECTIVES: Populations with reduced sensory and motor function are at increased risk of depression, anxiety and pain, and may be less geographically mobile. This study explored the efficacy and feasibility of web-based mindfulness training for people with spinal cord injury (SCI). SETTING: UK community sample. METHODS: Participants were randomly allocated to an 8-week online mindfulness intervention (N = 36), or to internet-delivered psychoeducation (N = 31). Depression symptom severity was the primary outcome. Secondary outcomes included anxiety, quality of life (QoL), pain perception, pain catastrophizing and mindfulness. Measures were taken before (T1), at completion of, (T2), and 3 months following the intervention (T3). RESULTS: At T2, ten participants discontinued mindfulness training, and five discontinued psychoeducation. Dropouts were of significantly older age. Nine participants were lost to follow-up. Mindfulness reduced depression significantly more than psychoeducation at T2 (mean difference = -1.50, 95% CI [-2.43, -0.58]) and T3 (mean difference = -2.34, 95% CI [-3.62, -1.10]). Anxiety, pain unpleasantness and catastrophizing were significantly reduced compared with psychoeducation. Total mindfulness scores, and all facets of mindfulness except observing were significantly higher following mindfulness training. At follow-up, reductions in anxiety and catastrophizing persisted. CONCLUSIONS: Internet-delivered mindfulness training offers unique benefits and is viable for people with reduced sensory awareness. Future work should explore the feasibility of combined education and mindfulness training. The use of brief interventions shows promise in maximizing participant retention.

Mindfulness interventions in medical education: A systematic review of their impact on medical student stress, depression, fatigue and burnout.

INTRODUCTION: Mindfulness-based interventions (MBIs) have gained popularity in medical education. A systematic review was conducted to determine the effectiveness of MBIs for reducing psychological distress in undergraduate medical students. METHODS: A search protocol was conducted using online databases Embase, PubMed, PsycINFO, and MEDLINE. Articles were required to meet the following criteria to be included: (1) describe a MBI or use of mindfulness exercises as part of an intervention, (2) include at least one of: stress, burnout, fatigue, or depression, as an outcome, (3) include quantitative outcomes, and (4) published in English in a peer-reviewed journal. RESULTS: Twelve articles were reviewed. Seven studies reported improvements in at least one targeted outcome. Four of seven studies exploring the impact on stress reported improvements. Five articles studying depression reported reductions. One study exploring burnout reported a decrease on a single subscale. Only one study measured the impact on fatigue (no change reported). Half of studies reviewed included predominantly female samples. CONCLUSIONS: Mixed evidence was found for the use of MBIs for reducing psychological distress in undergraduate medical students. Future work should aim to clarify the impact of mindfulness on burnout and fatigue, and explore the replicability of improvements in male medical students alone.

Visual reconstructions of endometriosis pain: An interdisciplinary visual methodology for illness representation.

OBJECTIVES: Endometriosis is a chronic condition in which tissue resembling the endometrium grows outside of the womb, causing severe chronic pain. Research demonstrates the physical, emotional and quality of life impact on people with endometriosis, but pain is reportedly difficult to communicate, resulting in lengthier diagnosis. This work aimed to gain insight into the value of imagery production as a pain communication strategy through a novel synergy of psychological and linguistic/socio-semiotic approaches. DESIGN: A qualitative, multimodal, participant-generated imagery study. METHODS: Interpretative phenomenological analysis (IPA) and conceptual metaphor and metonymy analysis were utilized to examine visual representations of endometriosis pain. Data were collected in two focus groups with four and six women, respectively; all with a diagnosis of endometriosis, aged 25-40 years old (M = 34.5, SD = 4.2) and a mean diagnosis delay of 8.4 years (SD = 3.6). RESULTS: The overarching theme across visual representations was 'Pain as Physical Violence' with 'colour as emotional representation', 'texture as sensory qualities' and 'materials as sensation' as sub-themes. These are realized through metaphorical and metonymical relations in both the visual representations as well as the accompanying linguistic representation of the process. CONCLUSIONS: This study demonstrates the value of a creative mixed-methodologies approach to capture experiential aspects of pain and its impact that are not verbalized in linguistic accounts alone. This can facilitate a deeper understanding of one's pain, acting as a medium for therapeutic adjustment to occur, while facilitating effective and empathic patient-professional conversations surrounding pain.

Isolated and anxious: A qualitative exploration of the impact of the COVID-19 pandemic on individuals living with spinal cord injury in the UK.

OBJECTIVE: People living with spinal cord injury (SCI) are often immunocompromised, and at increased risk of respiratory infection. Given the restrictions in response to the COVID-19 pandemic, those with SCI may be at increased risk of health deterioration, though how this is experienced is poorly understood. This study explored the experiences of people living with SCI during the COVID-19 pandemic. DESIGN: Participants completed an online survey consisting of demographic questions, and open-ended qualitative questions pertaining to their experiences during the pandemic. Thematic analysis was utilized for the analytical approach. SETTING: Community-based sample in the UK. PARTICIPANTS: Participants were recruited via social media outlets of UK-based SCI-specific support charities, and snowball sampling (N = 42, F = 34, M = 8). RESULTS: Key themes included: (1) lost access to health services and support, capturing concerns surrounding barriers to healthcare and rehabilitation, which intensified secondary consequences of SCI such as spasm and pain; (2) health anxiety, which was perpetuated by perceived heightened vulnerabilities to respiratory complications; (3) social isolation, with significantly reduced social contact, even with care providers, compounding health experiences. CONCLUSION: People living with SCI during the COVID-19 pandemic experienced a variety of personal physical, psychological, and social challenges, each of which could disrupt daily functioning and quality of life. Increased utilization of telehealth is recommended to support continued engagement in rehabilitation, and foster connection and community amongst others with SCI and health professionals.

Mindfulness practice correlates with reduced exam-induced stress and improved exam performance in preclinical medical students with the "acting with awareness", "non-judging" and "non-reacting" facets of mindfulness particularly associated with improved exam performance.

BACKGROUND: Medical students demonstrate higher levels of psychological distress compared with the general population and other student groups, especially at exam times. Mindfulness interventions show promise in stress reduction for this group, and in the reduction of cortisol, an established clinical marker of the body's stress response. This study investigated the relationship of mindfulness to exam-induced stress, salivary cortisol and exam performance in undergraduate medical students. METHODS: A controlled pre-post analysis design with within-groups comparisons. 67 medical students completed the five facet mindfulness questionnaire (FFMQ) and provided saliva samples, from which cortisol was extracted, during group work (control/baseline) and immediately prior to end of year 2 examinations (experimental). Academic performance data was extracted for comparison with measures. RESULTS: Exam-induced salivary cortisol concentration showed a significant negative relation with exam performance. Total FFMQ score showed a significant positive relation with exam performance and a significant negative relation with exam-induced salivary cortisol. The specific mindfulness facets of acting with awareness, non-judging and non-reacting also showed a positive correlation with exam performance. CONCLUSIONS: This study suggests that there exists an important relationship between mindfulness and the physiological biomarker of stress, cortisol, and this manifests into improved assessment outcomes potentially through healthier, more adaptive coping and stress management strategies. In particular, this study identifies the acting with awareness, non-judging and non-reacting facets of mindfulness to be significantly associated with exam performance suggesting that these may be important facets for clinical educators to target when helping students with mindfulness practice.

Parallel worlds and personified pain: A mixed-methods analysis of pain metaphor use by women with endometriosis.

OBJECTIVES: Endometriosis is a long-term condition in which endometrial-like tissue grows outside of the womb, causing intense chronic pain. Previous work has demonstrated the physical and emotional impact on women who live with endometriosis, and metaphors can play an influential role in communicating the experience of pain, but there exists little understanding of the role and impact of such language for women with endometriosis. DESIGN: A qualitative, semi-structured interview design. METHODS: Conceptual Metaphor Theory (CMT) and Interpretative Phenomenological Analysis (IPA) were utilized in a mixed-methods study to examine the prevalence, types, and meaning of metaphors and metaphor use as a health communication strategy. Twenty-one women aged between 23 and 53 years (mean age 36.1 years) with endometriosis took part in audio-recorded interviews. RESULTS: The women reported experiencing symptoms for an average of 11 years before receiving a formal diagnosis of endometriosis, and the mean age of diagnosis was 27.6 years. Seven distinct conceptual metaphors were identified in 221 metaphorical expressions used across all participants, with most common ones referring to pain as physical properties of elements such as temperature and pressure, physical damage, and an external attacker. IPA revealed three themes pertaining to the feeling of vulnerability and helplessness, pain being incomprehensible, and a drive to manage and conceal pain simultaneously. CONCLUSIONS: This study demonstrates the power of language in facilitating understanding and empathy in the listener, alongside the challenge of communicating endometriosis pain to others. Imagery-based techniques may assist in adaptation to, interpretation, and acceptance of pain to reduce pain-related distress.

'Trying to bring attention to your body when you're not sure where it is': An interpretative phenomenological analysis of drivers and barriers to mindfulness for people with spinal cord injury.

OBJECTIVES: Work is beginning to explore the impact of mindfulness in managing the physical and psychological health of people with spinal cord injury (SCI). However, no previous work has sought to understand what drives people with such conditions to try mindfulness, and what barriers are experienced in accessing mindfulness. DESIGN: An exploratory, qualitative, interview design, utilizing interpretative phenomenological analysis. METHODS: Semi-structured interviews were conducted with 11 people with SCI who had experience of mindfulness since sustaining their injury. Verbatim transcripts were analysed using IPA to understand the lived experience of mindfulness post-SCI. RESULTS: Analysis suggested that managing physical and mental health, and viewing mindfulness as proactive and protective were key drivers for exploring mindfulness. However, multiple barriers to accessing opportunities and developing capability impeded engagement. These included the focus on areas of the body that participants had reduced sensation in, physical environments that could not be navigated in a wheelchair, social stigma surrounding the use of mindfulness, and a sense of obligation and risk of failure implied by perceived requirements for engagement. CONCLUSIONS: The results demonstrate the need for specific interventions to accommodate the reduced sensory and physical function experienced by people with neurological conditions and to enhance sense of control and autonomy. In addition, recommendations include minimizing the stigma surrounding mindfulness, and the potentially demotivating impact of the perception of 'failing' to engage.

A systematic review and taxonomy of tools for evaluating evidence-based medicine teaching in medical education.

BACKGROUND: The importance of teaching the skills and practice of evidence-based medicine (EBM) for medical professionals has steadily grown in recent years. Alongside this growth is a need to evaluate the effectiveness of EBM curriculum as assessed by competency in the five 'A's': asking, acquiring, appraising, applying and assessing (impact and performance). EBM educators in medical education will benefit from a compendium of existing assessment tools for assessing EBM competencies in their settings. The purpose of this review is to provide a systematic review and taxonomy of validated tools that evaluate EBM teaching in medical education. METHODS: We searched MEDLINE, EMBASE, Cochrane library, Educational Resources Information Centre (ERIC), Best Evidence Medical Education (BEME) databases and references of retrieved articles published between January 2005 and March 2019. We have presented the identified tools along with their psychometric properties including validity, reliability and relevance to the five domains of EBM practice and dimensions of EBM learning. We also assessed the quality of the tools to identify high quality tools as those supported by established interrater reliability (if applicable), objective (non-self-reported) outcome measures and achieved ≥ 3 types of established validity evidence. We have reported our study in accordance with the PRISMA guidelines. RESULTS: We identified 1719 potentially relevant articles of which 63 full text articles were assessed for eligibility against inclusion and exclusion criteria. Twelve articles each with a unique and newly identified tool were included in the final analysis. Of the twelve tools, all of them assessed the third step of EBM practice (appraise) and four assessed just that one step. None of the twelve tools assessed the last step of EBM practice (assess). Of the seven domains of EBM learning, ten tools assessed knowledge gain, nine assessed skills and-one assessed attitude. None addressed reaction to EBM teaching, self-efficacy, behaviours or patient benefit. Of the twelve tools identified, six were high quality. We have also provided a taxonomy of tools using the CREATE framework, for EBM teachers in medical education. CONCLUSIONS: Six tools of reasonable validity are available for evaluating most steps of EBM and some domains of EBM learning. Further development and validation of tools that evaluate all the steps in EBM and all educational outcome domains are needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018116203.

Stigma and self-management: an Interpretative Phenomenological Analysis of the impact of chronic recurrent urinary tract infections after spinal cord injury.

STUDY DESIGN: Qualitative, phenomenological design. OBJECTIVES: Neurogenic bladder dysfunction and urinary tract infection (UTI) are common secondary consequences to neurological damage to the spinal cord. This study sought to establish the impact of chronic, recurrent UTIs on people with spinal cord injury (SCI). SETTING: Community sample, United Kingdom. METHODS: Twelve participants with SCI, aged between 28 and 68 years, who had experienced at least three recurrent UTI events within the previous 12 months were recruited. Detailed qualitative information was obtained from semi-structured interviews, which lasted between 30 and 60 min. Interpretative Phenomenological Analysis was performed to explore the lived experience of UTIs. RESULTS: Interview findings identified a range of factors related to the experience of recurrent UTIs in people with SCI. These were classified into the following themes: (1) Symptom Management Precedence, (2) Stigma-Motivated Risk Management and (3) Exhaustive Exploration of Treatment Options. Participants discussed management of acute exacerbations. Distress arose from perceptions of UTIs as potentially stigmatizing and fear of relying on antibiotics. Arising from this fear, many participants sought alternative prevention and management strategies. CONCLUSIONS: These results suggest that chronic recurrent UTIs act as major barriers to social participation, with adverse effects on quality of life of people with a neurogenic bladder after SCI. People with SCI would benefit from additional assessment of the impact of recurrent UTIs, so that healthcare professionals can address specific concerns, such as the psychosocial impact of urinary incontinence and stigmatizing views. Additional support to enhance self-management and facilitate social participation should be provided.

Neuropathic pain in a rehabilitation setting after spinal cord injury: an interpretative phenomenological analysis of inpatients' experiences.

STUDY DESIGN: Qualitative, semi-structured interviews. OBJECTIVES: Neuropathic pain (NP) can be psychologically and physically debilitating, and is present in approximately half of the spinal cord injured (SCI) population. However, under half of those with NP are adherent to pain medication. Understanding the impact of NP during rehabilitation is required to reduce long-term impact and to promote adherence to medication and psychoeducation recommendations. SETTING: United Kingdom. METHODS: Five males and three females with SCI and chronic NP, resident in rehabilitation wards at a specialist SCI center in the United Kingdom, took part. Semi-structured interviews were conducted with participants less than 15 months post-SCI (mean = 8.4 months). Verbatim transcripts were subject to interpretative phenomenological analysis (IPA). RESULTS: Three super-ordinate themes were identified, mediating pain and adherence: (1) the dichotomy of safety perceptions; (2) adherence despite adversity; and (3) fighting the future. Analyses suggest that experience of the rehabilitation setting and responsiveness of care shapes early distress. Attitudes to medication and psychosocial adjustment are relevant to developing expectations about pain management. CONCLUSIONS: Enhancing self-efficacy, feelings of safety in hospital, and encouraging the adoption of adaptive coping strategies may enhance psychosocial and pain-related outcomes, and improve adherence to medication. Encouraging adaptive responses to, and interpretation of, pain, through the use of interventions such as coping effectiveness training, targeted cognitive behavioral pain management, and acceptance-based interventions such as mindfulness, is recommended in order to reduce long-term reliance on medication.

The devil in the corner: A mixed-methods study of metaphor use by those with spinal cord injury-specific neuropathic pain.

OBJECTIVES: Metaphorical expressions of persistent pain play an influential role in the modulation of pain. This may be particularly distressing for those with physical disabilities such as spinal cord injury (SCI). Neuropathic pain (NP) after SCI is often described using metaphorical expressions such as burning and electricity. This study explored the use of metaphors by those with NP after SCI. DESIGN: A qualitative, semi-structured interview design was employed. METHODS: Data were analysed using content analysis (CA) and interpretative phenomenological analysis to explore prevalence of metaphor use and its meaning. Sixteen individuals aged between 23 and 82 years, with chronic NP (persisting for 3 months or longer), arising from SCI were interviewed in their homes or on hospital wards (M = 10, F = 6). Interviews lasted between 40 and 120 min. RESULTS: The results capture a range of metaphorical expressions embedded in participants' accounts. Three themes emerged: (1) pain as a personal attack, (2) the desire to be understood, and (3) conveying distress without adequate terminology. CA revealed that younger age, female gender, and outpatient status were associated with increased metaphor use. CONCLUSIONS: This study highlights the power of metaphor in eliciting understanding of NP after SCI from others, whilst demonstrating the challenge of communicating NP. Cognitive treatment that incorporates image-based techniques with acceptance and mindfulness-based therapies may encourage adaptive responses to, and interpretation of, pain. This may subsequently reduce pain-related distress and catastrophizing. Statement of contribution What is already known on this subject? Neuropathic pain is often described with metaphorical language such as burning and crushing. For those with physical limitations, metaphor use may induce or exacerbate psychological distress. However, for those with spinal cord injuries, metaphor use has received little attention. What does this study add? Metaphor use is common in those with spinal cord injury, with differences across gender and age. Core metaphors used conceptualized pain as an attacker or likened pain to heat and burning. Such language may have benefits in terms of improved understanding and increased empathy, but may be reflective of catastrophic thinking.