To determine the efficacy of treating neuropathic pain in spinal cord injury (SCI) patients by psychological, cognitive or behavioral therapies and suggest recommendations for clinical practices.
Material and method
The methodology used, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic review of the literature, the gathering of information regarding current clinical practices and a validation by a multidisciplinary panel of experts.
Due to the dearth of literature on the subject only one study is found, evaluating the efficacy of these therapies on neuropathic pain but not on the chronic neuropathic pain of SCI patients. The results show a greater efficacy on the associated symptoms: anxiety and depression level, sleep disorders, rather than the pain itself.
There is no scientific evidence for validating this type of pain management care. However, the high level of evidence of the articles studying the efficacy of these therapies in patients with chronic pain suggest that it could be applied to SCI patients. These techniques must be developed in France and further studies should be conducted on SCI patients affected by neuropathic pain.
Déterminer l’efficacité de la prise en charge de la douleur neuropathique du blessé médullaire par les thérapies psycho- ou cognitivocomportementales et proposer des recommandations de pratique clinique.
Matériel et méthode
La méthodologie utilisée, proposée par la Société française de médecine physique et de réadaptation (Sofmer), associe une revue systématique et critique de la littérature, un recueil des pratiques professionnelles, une validation par un panel pluridisciplinaire d’experts.
La littérature sur le sujet est pauvre et une seule étude est retrouvée, étudiant électivement l’efficacité de cette prise en charge dans les douleurs neuropathiques et non pas chroniques chez le blessé médullaire. Les résultats montrent plus d’efficacité sur les symptômes associés : niveau d’anxiété et de dépression, altération du sommeil, que sur la douleur elle-même.
Il n’y donc pas de preuve scientifique de la validité de ce type de prise en charge. Cependant, le bon niveau de preuve scientifique des articles étudiant l’efficacité de cette prise en charge chez des douloureux chroniques nous amènent à penser qu’il pourrait en être de même pour les blessés médullaires. Ces techniques doivent donc être développées en France et des études doivent être menées chez les blessés médullaires souffrant de douleurs neuropathiques.
Pain is a complex phenomenon when it becomes chronic, having a significant impact on the patients’ quality of life: sleep disorders, relationships with others, autonomy, depression feelings. It is the same for spinal cord injury (SCI) patients suffering from neuropathic pain, with associated symptoms, triggered by this pain: depressive syndrome, anxiety, feelings of hopelessness, sleep disorders and altered quality of life.
Furthermore, physicians and health care professionals are faced with conventional therapeutics, medications or surgical treatments that are insufficient for treating this type of pain. Thus it seems interesting to offer these patients a global pain management care, using psychological counseling as well as cognitive-behavioral treatments (CBT), that will help them have more control over their pain (coping strategies) and better manage the recurrent paroxystic episodes with self-management or self-care methods.
This kind of therapy in chronic pain management has many stages: first stage is studying the “body” and the painful phenomenon, improving the patients’ physical conditions with exercises and physiotherapy (according to the “activity pacing” theory: progressive exercising depending on the patients’ physical condition and their pain tolerance, alternating with resting periods). Second stage, getting back to an almost normal life by establishing daily life activities goals (in terms of leisures, work, domestic or social life) still following the activity pacing theory. Third stage is for patients to learn to manage their paroxystic pain episodes and improve the quality of their sleep using relaxation therapy, self-hypnosis, biofeedback (cognitive and behavioral therapies for turning the attention away from the pain and transforming it through imagery techniques). Then, the fourth stage aims at reducing the consumption of pain-relieving drugs, improving the patients mood and self-confidence (cognitive and coping strategies), learning to gain control over their pain by reinforcing the “good” pain management behaviors (behavioral management techniques). Finally, being able to retain the acquired psychological, cognitive and behavioral tools and strategies for pain management on the long-term .
This type of pain management care can be proposed individually or more often in group therapy with various protocols according to the various pathologies and nature of the pain.
Furthermore, the notion of “psychological/social” profile of the patient established using the Multidimensional Pain Inventory scale (MPI-SCI) with two types of profile in SCI patients (dysfunctional and adaptative coper), could lead to a better personalization of these therapeutics. The goal being to propose these psychological/behavioral treatments to specific profiles (dysfunctional) .
Materials and method
The keywords for selecting the articles were in French: thérapies psychocomportementales and blessé médullaire and douleur neuropathique. Douleur chronique and blessé médullaire . Thérapies psychocomportementales and blessé médullaire. Douleur chronique and thérapies psychocomportementales . The keywords in english were: psychological-behavioral therapies and spinal cord injury patients and neuropathic pain; chronic pain and spinal cord injury patients; psychological-behavioral therapies and spinal cord injury patients; chronic pain and psychological-behavioral therapies. Seventy articles were selected by the scientific committee, 29 were kept in the final selection and read for this literature.
The articles were critically and thoroughly read by two physicians from different specialties (Pain medicine and Physical Medicine and Rehabilitation), that benchmarked their results during two meetings in order to come up with a final synthesis. This final result was presented during the Experts Conferences with a vote from the attendees. Professional practices data collection was also done via the SOFMER website (SOFMER method).
Three articles were selected because they specifically matched the topic of our review and they associated three keywords: psychological-behavioral therapies, spinal cord injury patients and neuropathic pain ( Table 1 ).
|Group pain management therapy for persons with SCI
|Cundiff et al. USA
|Description of implementation of CBT in SCI
|6 sessions: 1 h/session: discussion + relaxation, breathing, self-hypnosis, coping strategies
|No scientific value
|Feasibility of a cognitive restructuring intervention for treatment of chronic in persons with disabilities
|Ehde and Jensen Washington
|Prospective non-comparative non-randomized
|18 patients including 10 SCI
|8 sessions: 90 min/session; 2 groups with cognitive (13) or educational therapy (5)
|At the end of the treatment
|Decrease in the pain intensity for the cognitive group, no importance in the educational group
|A comprehensive pain management program for neuropathic pain following SCI
|Prospective comparative non-randomized
|SCI: 27 Control group: 11
|20 sessions during a 10-week period Educational, CBT, relaxation Stretching Body awareness
|Decrease in the anxiety level and depression as well as number of medical visits, improved sleep quality
|Level 2 Grade B
The articles of Cundiff et al. and Ehde and Jensen studied the impact of psychological-behavioral therapies on the chronic pain of SCI patients (all types of pain), but with no real scientific value.
Only one article, Norrbrink Budh et al. reported the efficacy of psychological-behavioral therapies on the neuropathic pain of SCI patients, with a level 2 scientific evidence. It is a prospective, comparative, non-randomized study, including 27 SCI patients with chronic pain who volunteered for these therapies and a control group of 11 SCI patients with chronic pain. The inclusion criteria were: SCI dating back at least 12 months, suffering from neuropathic pain for at least 6 months (i.e. chronic pain) and lack of associated cranial trauma. The therapy consisted of 20 sessions over a 10-week period, including: educational sessions on pain management, CBT, relaxation, stretching and body awareness. Additional update sessions took place 3, 6 and 12 months after the first 10-week period. The follow-up took place at the end of the first 10 weeks as well as month 3, 6 and 12 with various evaluations: pain intensity (Borg CR 10 Scale, VAS pain), sleep quality (sleep questionnaire), quality of life (Nottingham health profile, Lisat 9), mood (HAD scale), sense of coherence (SOC instrument), and the frequency of medical visits and access to specialized care. The reported results show a decrease in the anxiety level and depression as well as lower number of medical visits, and improvement in the patients’ sleep quality review.
The evaluation of professional practices done during the Experts Conference and via the SOFMER website shows that 32% of French practitioners use psychological-behavioral therapy for neuropathic pain management in SCI patients, whereas 64% never or rarely propose it to their patients (Appendix A). Needless to say that these techniques are still badly known and rarely proposed by pain medicine physicians and not evaluated for this indication.
Furthermore, there are more studies on the impact of psychological-behavioral care in non-SCI patients with chronic pain. Morley et al. in a review and meta-analysis of 25 controlled, randomized studies on the efficacy of CBT on chronic pain shows a significant improvement in daily pain management, mood, coping with the pain as well as the emergence of “good” behaviors and an improvement in daily life activities and social interactions. It is important to note the excellent level of evidence of this meta-analysis rate at level 1.
There are very few studies focusing on the psychological-behavioral therapies proposed for treating neuropathic pain in SCI patients. Furthermore, the rare non-randomized, non-multicenter studies with very small groups of patients, are sometimes comparative and conducted essentially in Anglo-Saxon and Scandinavian countries.
Results show that these therapies are more efficient on the associated symptoms than on the pain itself and the level of scientific evidence is low.
We can objectively say that there is no real scientific evidence demonstrating the efficacy of these therapies on the chronic neuropathic pain of SCI patients. However, several studies focusing on patients affected by chronic pain (with a good level of scientific evidence) show that this type of care does help the patients to better cope with their pain and self-manage it. Thus, by analogy, we could hope that the impact would be the same on SCI patients affected with chronic neuropathic pain.
Conclusion and recommendations
The literature does not yield any arguments for recommending this type of treatment in SCI patients. It is barely used in France or used as separate therapies (for example, self-hypnosis therapy alone) and its efficacy has not been demonstrated yet. It could be relevant, however, to analyze in a prospective manner the impact of these techniques on the chronic neuropathic pain of SCI patients. This would imply training psychologists and physicians on the psychological-behavioral and CBT techniques as well as better defining the relevant indications: what type of care for which kind of patient.
Appendix A. Results of the questions asked to the 116 attendees of the SOFMER conference and the 50 physicians who answered via the SOFMER website.
Do you use cognitive-behavioral treatments for the pain management care of SCI patients with neuropathic pain?
dnk: does not know.