Abstract
Objective
In order to refine therapeutic strategies for spinal cord injury (SCI) patients with chronic neuropathic pain, it appears essential to assess the impact of socioenvironmental factors on the onset of pain or its chronic nature. The aim of this article is to answer the following question regarding these factors: is there any evidence that managing these social and environmental factors could have a positive impact on the treatment of chronic neuropathic pain in SCI patients?
Methodology
The English keywords were: Chronic neuropathic pain in spinal cord injury/human/adult and rehabilitation; functional independence; community integration; family support; employment; social environment; social support; life satisfaction; quality of life.
Results
Thirty-four articles were selected, the data extracted from the literature highlighted several socioenvironmental factors that could have a potential impact on the onset of neuropathic pain in spinal cord injury patients.
Conclusion
It was impossible to directly answer this question based on the literature review only. Nonetheless, some socioenvironmental factors can be considered as potential triggering factors for the onset of chronic pain in spinal cord injury patients, i.e. a low degree of independence (C), low socioeconomic status (B), unemployment (B), and family and friends with a “negative attitude” (C).
Résumé
Objectif
Afin d’affiner les stratégies thérapeutiques de la douleur neuropathique chronique du blessé médullaire, il paraît primordial de tenir compte de l’interaction de phénomènes socioenvironnementaux dans la genèse ou l’entretien de cette douleur chronique. L’objectif de ce travail est de répondre à la question suivante, traitant de ces éléments socioenvironnementaux : existe t-il des preuves d’efficacité de la prise en charge sociale et environnementale dans le traitement de la douleur neuropathique chronique du blessé médullaire ?
Méthodologie
Les mots clés anglais suivants ont été utilisés : Chronic neuropathic pain in spinal cord injury/human/adult and rehabilitation; functional independence; community integration; family support; employement; social environment; social support; life satisfaction; quality of life . Les mots clés français suivants ont été utilisés : douleur chronique chez le blessé médullaire traumatique/humain/adulte et adaptation sociale ; réadaptation ; insertion professionnelle ; emploi ; environnement social ; réinsertion sociale ; environnement familial ; qualité de vie.
Résultats
Trente-quatre articles ont alors été sélectionnés, les données de la littérature mettant en avant plusieurs facteurs socioenvironnementaux susceptibles d’interférer dans la genèse de la douleur neuropathique du blessé médullaire.
Conclusion
La revue de la littérature ne permet pas de répondre directement à la question posée. Cependant, certains facteurs socioenvironnementaux peuvent être considérés comme facilitant la survenue de douleurs chroniques du blessé médullaire : un niveau de dépendance élevé (C), un faible niveau social (B), une désinsertion professionnelle (B), un entourage « négatif » (C).
1
English version
1.1
Introduction
To correctly manage the neuropathic pain of spinal cord injury (SCI) patients it is essential to understand all the factors that could have an impact on this pain or trigger its onset.
In order to refine therapeutic strategies for SCI patients with chronic neuropathic pain, it appears essential to assess the impact of socioenvironmental factors on the onset of pain or its chronic nature.
The aim of this article is to answer the following question regarding these factors: is there any evidence that managing these social and environmental factors could have a positive impact on the treatment of chronic neuropathic pain in SCI patients?
1.2
Methodology
The following keywords were used in the English language: Chronic neuropathic pain in spinal cord injury/ human/ adult and rehabilitation; functional independence; community integration; family support; employment; social environment; social support; life satisfaction; quality of life.
The following keywords were used in the French language: douleur chronique chez le blessé médullaire traumatique/humain/adulte et adaptation sociale ; réadaptation ; insertion professionnelle ; emploi ; environnement social ; réinsertion sociale ; environnement familial ; qualité de vie .
Two expert readers were in charge of the data collection from the literature, one is a Physical Medicine and Rehabilitation (PM and R) specialist and member of the International French-Speaking Association for Groups Focusing on Spinal Cord Injury – Association francophone internationale des groupes d’animation de la paraplégie (Afigap), the other one is a psychiatrist and a member of the French Society for Pain Evaluation and Treatment – Société française d’évaluation et de traitement de la douleur (SFETD). They proceeded with an independent selection and analysis of the articles. This analysis was completed by other relevant articles brought to the attention of the two experts or articles listed in the references of the selected articles.
1.3
Results
Seventy-one articles were listed and sent to the experts by the scientific committee. Among these 71 articles, none answered this question directly.
Given the role played by socioenvironmental factors in interpreting the pathophysiology of pain, the experts chose to include the notion of social and environmental predictive factors to try and formulate an answer to this question and propose a framework for integrating these factors in the chronic pain management of SCI patients.
In order to answer this question for the scientific committee, a second lecture of the literature was mandatory. Thirty-four articles were then selected and listed in the enclosed table, the data found in the literature unveiled several socioenvironmental factors that could have an impact on the onset of neuropathic pain in SCI patients ( Table 1 ).
| n | Type of study | Level of evidence | Pain prevalence % | Age | Sex M | Sex F | Race | Low degree of independence | Depression anxiety | Negative family attitude | Socioeconomic status/Work | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Anke et al., | 46 | NR | 2 | 46 | + | + | + | + | ||||
| Burke | 360 | NR | 1 | 46 | + | + | – | |||||
| Cardenas et al., | 7379 | Questionnaire | 1 | 81 | – | – | + | + | ||||
| Cruz-Almeida et al., | 123 | NR | 2 | – | – | – | + | + | ||||
| Dalyan et al., | 130 | NR | 2 | 76 | + | – | ||||||
| Demirel et al., | – | NR | 2 | – | + | – | – | |||||
| Donnelly et al., | 66 | Prospective | 2 | 86 | + | – | + | |||||
| Finnerup et al., | – | NR | 2 | 77 | + | |||||||
| Gerhart et al., | 121 | NR | 2 | 25 | + | |||||||
| Giardino et al., | 74 | NR | 2 | 100 | + | + | ||||||
| Henwood et al., | 24 | NR | 2 | – | + | |||||||
| Jensen et al., | 147 | NR | 1 | 79 | + | + | + | + | ||||
| Kennedy et al., | 76 | NR | 1 | 77 | + | |||||||
| Kennedy et al., | 1000 | Questionnaire | 1 | – | + | |||||||
| Klotz et al., | 1668 | NR | 1 | – | + | + | ||||||
| Lundqvist et al., | 98 | NR | 2 | 26 | ||||||||
| Mathew et al., | 4 | Case report | 4 | – | + | |||||||
| Nepomuceno et al., | 200 | NR | 1 | 48 | + | |||||||
| Norrbrink Budh et al., | 456 | NR | 1 | 46 | + | + | + | |||||
| Putzke et al., | 540 | Longitudinal | 1 | 72 | + | – | + | |||||
| Putzke et al., | 270 | NR | 1 | 71 | + | – | – | + | ||||
| Richards et al., | 75 | NR | 2 | 77 | + | – | – | + | + | |||
| Rintala et al., | 77 | NR | 2 | 75 | – | + | + | + | ||||
| Rose et al., | 885 | NR | 1 | 69 | + | |||||||
| Siddal et al., | – | Review | 1 | 99 | + | – | + | + | ||||
| Siddal et al., | – | Review | 1 | 65 | + | |||||||
| Siddal et Middleton | – | Review | 1 | – | + | + | ||||||
| Störmer et al., | 215 | NR | 2 | 44 | + | + | + | |||||
| Stroud et al., | 70 | Questionnaire | 2 | 100 | + | + | ||||||
| Summers et al., | 54 | Questionnaire | 1 | 78 | – | + | + | |||||
| Turner et al., | 384 | Questionnaire | 1 | 79 | – | – | – | – | + | |||
| Turner et al., | 174 | Questionnaire | 1 | 75 | – | – | + | |||||
| Werhagen et al., | – | NR | 2 | 40 | + | – | – | |||||
| Widerström-Noga et al., | 159 | Questionnaire | 2 | 100 | + | + |
1.4
Discussion
The chronic neuropathic pain of SCI patients has been the focus of many studies and gave way to several pathophysiological hypotheses, all implying intrinsic action mechanisms : physical, psychological or social . Chronic pain has a major negative impact in terms of quality of life, functional impairment and social activities for SCI patients . Rose et al. report also that 18% of SCI patients are unable to get back to work because they are so impaired by their pain . To understand and properly manage chronic pain in SCI patients, it seems highly relevant to take into account all etiopathogenic factors that could potentially interfere with this pain.
In 1977, Engel was the first to introduce the notion of a biopsychosocial model for understanding the pain’s action mechanisms and Richards et al. at the beginning of the eighties underlined again the important role played by socioenvironmental factors on this pain , this was again reported by Siddal and Middleton in 2006 in the study of chronic neuropathic pain in SCI patients . From that point on, it seemed essential to take into account the psychosocial environment of SCI patients for efficiently treating their neuropathic pain. . For some other authors, it would be relevant to look for predictive socioenvironmental factors that could have a impact on the onset of chronic neuropathic pain. The goal being to identify these factors, act on them and integrate them as part of the chronic pain management of SCI patients. Only a few studies tried to bring forward these socioenvironmental factors .
1.4.1
The patient’s age
Being old at the time of the initial injury has often been labelled as a negative factor for the prevalence of chronic neuropathic pain in SCI patients.
Conversely, only two studies (level 2 of evidence) report the exact opposite with a higher pain prevalence in younger SCI patients.
1.4.2
Gender
The data from the literature are contradictory. Four studies (2 are level 2 and 2 are level 1) showed that women suffer more than men .
Twelve studies stated the exact opposite. The heterogeneous data are directly linked to the predominant male SCI population with a bias in the studies’ sample groups.
1.4.3
Race/ethnicity
Five studies reported a disparity between populations with different ethnic origins. However theses differences could not be validated as a predictive factor .
1.4.4
Independence
Seven studies highlighted that patients in pain have a lower degree of independence . No correlation was validated however between a low degree of independence and the onset of chronic neuropathic pain.
1.4.5
Family and friends
The family and social environment of SCI patients both seem to have an impact on how they perceive and cope with their pain . Family environment was often described as having a negative impact on this pain and could even foster the pain’s action mechanisms. In some cases, the comfort, care and help provided by the spouses could reinforce the pain or maintain a low degree of independence .
However, family should be involved in the chronic pain management of SCI patients, 63% of the physicians surveyed during the Sofmer conference take family and social environments into account when treating their SCI patients for chronic pain ( Appendix A ).
In fact, 44% of the physicians who answered the survey during the Sofmer conference think that starting with an early non-pharmaceutical treatment could help prevent the onset of chronic neuropathic pain in SCI patients ( Appendix A ).
1.4.6
Socioeconomic status and work
Some authors described the negative impact of a low socioeconomic status on the severity of pain. Five studies (level 1 of evidence) highlight that low socioeconomic status and unemployment could be seen as a negative predictive factor for the onset of chronic neuropathic pain in SCI patients. In fact patients that are able to get back to work report less pain than the others . Furthermore, Henwood et al., in 2004, unveiled that when SCI patients increased their social interactions and activities, it relieved their pain and improved their quality of life .
1.4.7
Adapted home environment and financial income
No study brought forward the impact of an adapted home environment or financial income on the onset of pain.
1.5
Conclusions and recommendations
Some socioenvironmental factors could be considered as predictive factors for the onset of chronic neuropathic pain in SCI patients and they could potentially be modulated. Some of these factors cannot be changed: age, gender, race/ethnicity (level of recommendation C).
However, some of them can be considered as trigger factors for the onset of neuropathic pain in SCI patients (C): low degree of independence seems to be a negative prognostic factor (C). Family and social environment of SCI patients can play a role on how they perceive and cope with their chronic neuropathic pain (C). Low socioeconomic status and unemployment can also have a negative impact on the onset of chronic pain in SCI patients (B).
An early identification of these factors could help improve the pain management care of these patients. A multidisciplinary treatment approach seems essential and consensual to provide the best possible pain management care to SCI patients.
Appendix 1
Results from the questions asked to the 116 physicians who attended the SOFMER Conference and the 50 others who answered via the website.
Do you involve the family in the chronic neuropathic pain care of SCI patients?
- •
Yes: 63,49%
- •
No: 34,10%
Do you think that an early non-pharmaceutical treatment could help prevent the onset of chronic neuropathic pain in SCI patients?
- •
Yes: 44,39%
- •
No: 52,60%
2
Version francaise
2.1
Introduction
La prise en charge de la douleur neuropathique du blessé médullaire implique la connaissance de l’ensemble des facteurs susceptibles de la modifier ou d’en favoriser l’apparition.
Afin d’affiner les stratégies thérapeutiques, il paraît primordial de tenir compte de l’interaction de phénomènes socioenvironnementaux dans la genèse ou l’entretien de cette douleur chronique.
L’objectif de ce travail est de répondre à la question suivante, traitant de ces éléments socioenvironnementaux : existe t-il des preuves d’efficacité de la prise en charge sociale et environnementale dans le traitement de la douleur neuropathique chronique du blessé médullaire ?
2.2
Méthodologie
Les mots clés anglais suivants ont été utilisés : Chronic neuropathic pain in spinal cord injury/human/adult and rehabilitation; functional independence; community integration; family support; employement; social environment; social support; life satisfaction; quality of life .
Les mots clés français suivants ont été utilisés : douleur chronique chez le blessé médullaire traumatique/humain/adulte et adaptation sociale ; réadaptation ; insertion professionnelle ; emploi ; environnement social ; réinsertion sociale ; environnement familial ; qualité de vie.
Les deux experts, étaient l’un spécialiste de MPR, membre de l’Association francophone international des groupes d’animation de la paraplégique (Afigap), l’autre psychiatre, membre de la Société française d’évaluation et de traitement de la douleur (SFETD) pour sélection et analyse indépendantes. Ces références ont été complétées par d’autres articles portés à la connaissance des experts ou cités dans les articles recensés.
2.3
Résultats
Soixante et onze articles ont été recensés et transmis par le comité scientifique aux experts de la question posée. Parmi les 71 articles, aucun ne répondait directement à la question posée.
Compte tenu de l’importance connue des facteurs socioenvironnementaux dans l’interprétation de la physiopathologie de la douleur, les experts ont choisi d’intégrer la notion de facteurs prédictifs sociaux et environnementaux pour tenter de répondre à la question et de proposer un schéma de prise en compte de ces facteurs dans le traitement de la douleur chronique neuropathique du blessé médullaire.
Une seconde lecture de la littérature a donc été nécessaire afin de répondre au comité scientifique. Trente-quatre articles ont alors été sélectionnés et regroupés dans le tableau suivant, les données de la littérature mettant en avant plusieurs facteurs socioenvironnementaux susceptibles d’interférer dans la genèse de la douleur neuropathique du blessé médullaire ( Tableau 1 ).
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