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K - Ameliorate Neuropathic Pain

There have only been a small number of experimental studies addressing the efficacy of pain treatments, in the SCI population, despite the high prevalence of pain and its major impact on their lives. As a result, little progress has been made in developing truly effective treatments. Table 1.0 lists current evidence-based treatments. Table 1.0 Evidence Base for Treatment of Neuropathic Pain After Spinal Cord Injury (adapted from SCIRE Version 4).9 From the available evidence on maximizing the success of pain management after SCI, it is important to apply a team-based approach that combines both pharmacologic and non-pharmacologic therapies. In addition, some researchers are exploring ways to prevent neuropathic pain before it develops. Current Clinical Practice Twelve E-Scan sites provided data regarding pain management practices. All sites report access to pain management services, for inpatients; and 10 sites report access for outpatients. Most of these programs are onsite or within the organization, with three of 12 external to the organization. Services within the organization are important to ensure accessibility and timely access. Nine of twelve sites report adequate wait times. Despite universal access to pain management services, only seven of 12 sites report those services to be adequate. Since early intervention is critical to successful pain management, this pattern is a concern. Few sites report routine use of any type of standardized assessments, for either diagnosis or treatment of pain. The most common tool - used in seven of 12 sites, but only routinely at five - is the visual analog scale (VAS) for pain. Simple and easy to use, this is a well-validated tool for getting baseline assessments for pain, and for determining response to treatment. The Brief Pain Inventory (BPI) and the Multidimensional Pain Inventory (MPI) - also well validated for pain assessment and follow up, with the added benefit of a function component - are only used by three of 12, and four of 12 sites, respectively. In the diagnosis of neuropathic pain, less than half the sites use any validated tools. Five of twelve sites report using the DN4 questionnaire, and one-twelfth report using the S-LANSS. To improve post-SCI management of NeP in Canada, it is imperative that sites possess the knowledge and tools to ensure a uniform approach to diagnosis, assessment and follow up. Related to treatment guidelines for managing NeP, only three of 12 sites follow a standard of care, and only three of 12 sites follow any kind of clinical practice guidelines. Spinal Cord Injury Rehabilitation Evidence (SCIRE) - a Canadian, evidence-based document for SCI rehabilitation care - contains an excellent guide for management of pain after SCI (www.scireproject.com).9 A summary of these pharmacologic management recommendations was published in 2010.11 Another excellent, non-Canadian publication has been written by Siddall.12 Only one of 12 sites report routine use Siddall’s guidelines, and only two of 12 sites report using the SCIRE systematic review to guide practice. Next steps, for enhancing treatment of NeP, require uptake and implementation of current evidence and clinical practice guidelines. Treatment Level of Evidence Treatment Efficacy Pharmacologic Interventions - Oral and Topical Pregabalin Level 1 + Gabapentin Level 1 + Lamotrigine* for incomplete SCI only Level 2 + Amitryptyline* post-SCI patients, Level 1 + with depression and pain only Tramadol Level 1 + Topical capsaicin for radicular pain post SCI Level 4 + Levetiracetam Level 1 - Valproic acid Level 1 - Trazodone Level 1 - Mexilitene Level 1 - Pharmacologic Therapy – Intravenous Administration Intravenous alfentanil* for short-term relief Level 1 + Intravenous morphine for mechanical allodynia* Level 1 + for short-term relief Intravenous ketamine* for short-term relief of allodynia Level 1 + Intrathecal lidocaine * for short-term pain relief Level 1 + Pharmacologic Therapy - Intrathecal Intrathecal morphine plus clonidine Level 2 + Intrathecal baclofen for dysesthetic pain Level 1 + Intrathecal clonidine Level 1 - Non-Pharmacologic Therapy Heat and massage Level 4 + Accupuncture and electroacupuncture Level 4 + Regular exercise Level 1 + Hypnosis Level 4 + Cognitive behavioural pain management Level 2 + with pharmacological treatment Visual imagery Level 4 + Transcranial electrical stimulation Level 1 + Cognitive behavioural pain management alone Level 2 - Surgical Therapy Spinal cord stimulation Level 4 + Dorsal root entry zone ablation Level 4 + 108 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


K - Ameliorate Neuropathic Pain
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