1.1

Introduction

Physical therapy is an entity with a badly defined and non-consensual framework. It involves medical and physiotherapy teams. Largely based on experience, it encompasses a group of techniques with a therapeutic aim based on physical contact using tactile stimuli, electrical or magnetic stimulation.

For pain-relieving treatment, physical therapies are based on joint mobilization and massages as well as electrophysiotherapy. The latter combines transcutaneous electrostimulation (TENS), cold or hot applications, thermotherapy, electrotherapy, electromagnetic waves therapy, laser phototherapy, vibrations, ultrasound therapy.

For spinal cord injury (SCI) patients, their daily routine leaves very little room for physical therapy in treating their central neuropathic pain.

The aim of this literature review is to assess the real place of these therapies within the therapeutic array available for treating central neuropathic pain in chronic SCI patients.

1.2

Methods

1.3

Results

The bibliographical search conducted by the scientific committee found 71 articles. The full-text analysis, the analysis of the references of the selected articles as well as personal research led to isolating 39 articles that met the above-mentioned inclusion criteria.

The final selection combined methodological criteria-controlled study, randomized vs. placebo or crossover study or non-randomized study, cohort size criteria or singularity of the obtained results. Finally, 17 studies made the final cut. Ten studies directly focused on magnetic or electrical transcranial stimulation ( Fig. 1 ), four studies were on pain-relieving transcutaneous neurostimulation ( Fig. 2 ), and three on acupuncture ( Fig. 3 ). The presentation in each table lists the cohort size, study methodology, control level for the confusion factors and level of scientific proof. The other physical therapies were only brought up, in an anecdotic manner, in so-called “general” articles on neuropathic pain in SCI patients. An inadequate or even lack of methodology and/or the lack of references to a therapeutic study and/or a very small sample group of patients did not yield any article on all other physical therapies.

Publications selected for electrical or magnetic transcranial stimulation.

Publications selected for transcutaneous neurostimulation (TENS) .

Publications selected for acupuncture .

No discordance was noted between the two experts for establishing the level of scientific proof. In spite of their rigorous clinical study methodology, some articles were downgraded from level 2 to level 4 due to major biases among which we find the weak representation of SCI patients within an heterogeneous group of patients and not taking into account the confusion factors .

Only one literature review was selected because it was conducted by one of the most specialized team in this field of expertise .

For pain-relieving transcutaneous neurostimulation, the dearth of publications combining “neuropathic pain” and “SCI patients” led to keeping only articles that strongly suggested a therapeutic impact either because the number of included patient was high, or because the effects were spectacular for some patients.

Regarding professional practices, 166 individuals (116 who attended the Experts Conference and 50 who answered via Internet) gave their opinion on using physical therapy for treating chronic neuropathic pain ( Appendix 1 ). The answers highlighted the predominance of pain-relieving transcutaneous neurostimulation as the main option for treating below-level central neuropathic pain and segmental neuropathic pain (at the level of injury).

1.4

Discussion

1.5

Acupuncture

We found only non-controlled, prospective or retrospective studies coming from two different authors and dominated by two techniques: Nayak et al. (regular acupuncture) and Rapson et al. (electroacupuncture).

The only prospective study is Canadian . It is a non-controlled study on the efficacy of acupuncture on chronic pain in SCI patients and thus on their physical and social behavior as well as their mood and psychological state. The study also aimed to identify the predictive factors for a positive response to acupuncture in 31 SCI patients with an injury dating back at least 6 months who report a pain intensity above or equal to 5/10 for at least the past 6 months. The treatment was administered during 7,5 weeks over 15 sessions and the multidimensional evaluation associated a numeric rating pain scale, a global medical check up, an overview of the patients’ social activities, mood assessment, psychological check-up as well as an evaluation the patients well-being and their expectations regarding the treatment.

This evaluation was done prior to the treatment ( t ₀ ), during the treatment ( t ₀ + 7,5 weeks), after treatment ( t + 15 weeks) and ( t + 28 weeks). Among the 31 patients included, 22 completed the study. The mean time since injury was estimated at 8,49 years and mean duration of pain at 8,46 years. The decrease in pain intensity is significant and lingers on for 3 months. Eighteen percent of patients reported a decrease of more than 3 points on the numeric rating scale (NRS), 27% between two and three points, 37% between zero and two points and 18% report a pain increase.

Overall, almost 54,5% of patients (i.e., 12 patients) judged acupuncture useless or with a minimal or even worsening action on their pain. But, 46% of patients benefited from this treatment and for 41% of them the positive impact lasted up to 3 months ( p < 0.01). However, in this group, the patients with below-level central neuropathic pain did not respond positively to the treatment ( p < 0.01). No significant clinical or demographical difference distinguishes the improved group from the non-improved group.

This study suggests that the incomplete patients (60% of surveyed patients) are more likely to belong to the improved group. (33% in complete patients) and the best response level is obtained for musculoskeletal pain (42% of surveyed patients) rather than below-level central neuropathic pain. The only significant difference observed between the improved and non-improved group is the level of pain intensity before treatment. The best results were for patients with a low intensity pain. There are no reported significant changes on the patients’ mood, anxiety level or depressive state. Finally, the negative impact of pain on daily life activities significantly decreases in the improved group after treatment ( p < 0.01). The lack of a control group makes it impossible to discard the placebo effect.

Two retrospective studies are associated to this first publication they are both selected for our review since the first one is based on a cohort of 77 SCI patients and the second one is conducted with a strict methodology and an independent double-reading of the results.

The first one is a retrospective study on the framework and guidelines for complementary and alternative medicine (CAM) used for treating chronic pain in SCI patients .

From an initial sample group of 135 patients, 77 SCI patients were contacted by phone (response rate 57%). Among these patients, 15 had already been involved in a therapeutic clinical study on acupuncture but no demographical and clinical data could differentiate them from the other 62 patients. The phone conversation focused on demographics, type of pain and duration of pain, use of conventional therapies as well as CAM during the survey or prior to it, the reasons for selecting CAM, the cost of these therapeutics, the insurances financial support, the type of CAM and their treatment details (duration, frequency, benefit received, adverse events).

Forty-three patients (56%) had already benefited from CAM (25 had given up at the time of the survey, 18 were still involved in CAM). Among these 43 patients, we account for 1 patients included in the acupuncture clinical study, but for 12 of these 15 patients, it is their first and only CAM experience. No differences were reported regarding sex, ethnic origin, age or educational level between users and non-users. No difference was reported in terms of pain severity. We can differentiate the users through some characteristic traits, better income, the time since injury is longer and their pain is twice more important than others. The time spent on CAM varies from 4 to 18 months (mean 3,64 years). Most patients have been users for the past 1 to 2 years. Among the users, the reasons for turning to CAM were, in decreasing frequency order, inefficacy of conventional treatments (88,9%), the desire for a treatment taking into account the relationships between mind, body and soul (66,7%), the desire to better control their therapeutic care (55,6%), the desire to explore all existing therapeutic possibilities (38,9%), recommended by a physician. Among the non-users, the reasons for not using CAM were, in decreasing frequency order: never considered CAM as a valid therapeutic option (41,2%), no easy access to CAM or no info on CAM (14,7%), unable to afford CAM (11,8%), not reimbursed by their medical insurance (8,8%), physician did not recommend CAM (8,8%), does not believe in CAM (8,8%). Among the users who gave up CAM, the reasons for giving up were, in decreasing frequency order: inefficacy of CAM, unable to continue affording CAM, not reimbursed by medical insurance, no noticeable improvement. The demographical and clinical data analysis was done by logistical regression. It appears that only the age of the injury and the use of conventional pharmaceutical treatments are predictive factors for using CAM.

Meaning that, for each additional decade, the odds of turning to CAM are three times more important. Those who never used conventional medications are 6,5 times more likely to turn to CAM.

Among the users, the wide use of conventional pharmaceutical drugs is a predictive factor for a scale-down use of CAM.

The CAM used in decreasing frequency order are acupuncture (15/31, 48.4%), massages (8/31, 25.8%), chiropractic (7/31, 22.6%) and phytotherapy (6/31, 19.4%).

Two techniques emerge but in different ways: acupuncture is the most used CAM but the one deemed less efficient and massage is the least used CAM but the one deemed the most beneficial. This issue is still being debated. The CAM utilization rate in this population seems similar to that of the general population. The authors underline one more time. the need for controlled clinical trials.

The other publication is also a retrospective study on the painful future of SCI patients (traumatic and non-traumatic SCI) treated by electroacupuncture for below-level central neuropathic pain . The aim was to identify the improved and non-improved profiles.

The patients were treated by electroacupuncture while continuing to take their usual medications. They were evaluated with a double reading, in case of disagreement, a third independent reader settled the issue. Thirty-six patients with duration of pain ranging from 2 weeks to 15 months were included. Twenty-four patients reported an improvement on their pain intensity. Twelve patients reported no improvement. The difference is quite significant.

Among the 24 patients, the significant factors for responding positively to the treatment were:

• •
  

  bilateral nature of the pain;

  
  
• •
  

  symmetrical nature of the pain.

Patients with isolated burning pain were the most likely to improve.

The continuous nature of the pain did not significantly differentiate the patients who reported an improvement from those who did not. But when it is associated to the two factors mentioned above, it increases the discriminative power between improved and non-improved patients.

No adverse events were reported (no bleeding, infection or autonomic dysreflexia).

This study suggests the potential pain-relieving action of electroacupuncture by targeting its action on below-level central neuropathic pain in SCI patients. It is proposed as a secondary therapy in case of lack of responses to conventional medications.

No indication on the lingering postsession effect is reported.

1.6

Other physical therapies

When conventional physical therapies (massages, joint mobilization, thermotherapy, etc.) are found in the literature they are part of retrospective studies to evaluated the place of these therapies in treating central neuropathic pain in SCI patients.

If in the Norrbrink and Lundeberg publication , the massages and hot thermotherapy are validated as efficient by, respectively, 87 and 77% of patients, it is impossible to know which pain is targeted (nociceptive, central neuropathic or mixed). The authors recommend to continue using these therapies until the proof of their efficacy is validated.

The conclusions are quite similar for Cardenas and Jensen . The authors, after analyzing the results of a survey of 336 SCI patients, established for 117 of them suffering from chronic central neuropathic pain, a hierarchical ranking of efficient alternative treatments. Regarding physical therapies we find massages (55% of efficacy). Chiropractic (27% of efficacy) and biofeedback (23% of efficacy) are found at the bottom of the list with short postsession lingering positive effects.

In an another survey conducted by Nayak et al. , massages appear once again among the most efficient therapies without any possibilities to determine what type of pain is targeted.

Finally, a last publication is relevant because it underlines the risk of using poorly-indicated physiotherapy in treating central neuropathic SCI pain, aggravated by effort and that evokes the diagnosis of arachnoiditis .

It is also important to mention a study that underlines that acupuncture is not risk-free in quadriplegic patients with a neurovegetative risk and that autonomic dysreflexia episodes can occur between sessions .

Healthcare professionals recommend choosing pain-relieving transcutaneous neurostimulation as the first therapeutic option for treating central neuropathic pain. We have to agree that besides massages restricted to below-level areas and electrotherapy proposed for two types of pain, the other physical therapies remain quite confidential (less than 5% of users). We will note, however, that transcranial stimulation is now the choice of 3.49% of prescribing physicians for below-level central neuropathic pain.

1.7

Recommendations and conclusion

This literature review focusing on the impact of physical therapies on central neuropathic pain in patients, and more largely in SCI patients, shows how very few publications are available on these therapies used in SCI patients and how difficult and insufficient it is to implement a rigorous methodology in this context. Our review reports that three therapies dominate the literature: magnetic or electrical transcranial stimulation, pain-relieving transcutaneous neurostimulation and acupuncture.

Only the first one offers a literature rich in controlled randomized studies, either double-blind or crossover. Unfortunately some negative methodological aspects reduce the impact of their conclusions: insufficient characteristics regarding the type of pain, heterogeneous groups of patients, sample groups of traumatic or non-traumatic SCI patients that are too small, lack of control over the confusion factors (mainly those related to the patients mood and psychological state).

The clinical practices recommendations are labeled as grade B relative to randomized, low-power studies and underline the need to expand the studies in a more homogenous manner to SCI patients with a better control over the best known confusion factors, i.e. depression and anxiety.

Regarding acupuncture and pain-relieving transcutaneous neurostimulation, both techniques seem “promising” in terms of pain-relieving efficacy: for acupuncture on segmental neuropathic pain as well as below-level central neuropathic pain and for transcutaneous neurostimulation on segmental pain (at the injury level).

No controlled, randomized study can validate a preference. The harmlessness of these therapies is quite relative since transcutaneous neurostimulation is not recommended for allodynia and some cases of autonomic dysreflexia were reported during acupuncture sessions. However, these techniques if they are correctly administered only report some rare incidents and can be used daily. The publications on acupuncture and transcutaneous neurostimulation are labeled as grade C.

For all other techniques there are no potential application perspectives for treating neuropathic pain in SCI patients. Massages are defended by patients themselves without any physiological validation or clinical arguments (prospective or retrospective studies) to suggest further controlled clinical studies.

Appendix 1

Vote results (116 attendees from the Experts Conference + Internet 50 voters)

2.1

Introduction

La thérapie physique est une entité dont les contours sont mal définis et non consensuels. Elle concerne aussi bien des actes médicaux que kinésithérapiques. On y regroupe par expérience toutes les techniques à vocation thérapeutique fondées sur un contact physique et faisant appel à l’application de stimuli tactiles, de courants électriques ou de courants magnétiques.

Dans le traitement de la douleur, les thérapies physiques relèvent, en pratique courante, de la mobilisation articulaire et des massages ainsi que de l’électrophysiothérapie antalgique. Cette dernière associe l’électrostimulation transcutanée (TENS), l’application de froid ou de chaud, la thermothérapie, l’électrothérapie, le traitement par ondes électromagnétiques, l’énergie lumineuse, les vibrations, l’application d’ultrasons.

Chez le blessé médullaire, la pratique quotidienne réserve peu de place aux thérapies physiques pour traiter les douleurs neuropathiques.

Le but de la revue de la littérature est de faire le point sur la place réelle de ces thérapies dans l’arsenal thérapeutique de la douleur neuropathique chronique chez le blessé médullaire en phase séquellaire.

2.2

Méthodes

2.3

Résultats

La recherche bibliographique réalisée par le comité scientifique a retrouvé 71 articles. L’examen en texte entier et l’analyse des références des articles sélectionnés ainsi que la recherche personnelle ont permis d’isoler 39 articles éligibles sur la base des critères d’inclusion précités.

En associant des critères méthodologiques – étude contrôlée, randomisée contre placebo ou en crossover ou non randomisée – des critères de taille d’échantillon ou de singularité des résultats obtenus, 17 études ont été retenues. Dix études sont directement focalisées sur la stimulation magnétique ou électrique transcrânienne (Fig. 1) , quatre études concernent la TENS (Fig. 2) , et trois portent sur l’acupuncture (Fig. 3) . La présentation des publications dans chacun des tableaux fait état de la taille de l’échantillon représenté, de la méthodologie de l’étude, du niveau de contrôle des facteurs de confusion et du niveau de preuve scientifique. Les autres thérapies physiques n’ont été abordées que de manière anecdotique dans des articles dits « généralistes » sur la douleur neuropathique chez le blessé médullaire. L’insuffisance, voire l’absence de méthodologie et/ou l’absence de référence à un essai thérapeutique et/ou un échantillon de patients très petit, n’ont permis de ne retenir aucun écrit portant sur toutes les autres thérapies physiques.

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