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Study design:Descriptive study with a cross-sectional design.Objectives:To describe the epidemiology of traumatic spinal cord injuries (TSCIs) in Botswana, with a specific focus on road traffic crashes (RTC).Setting:Main public referral hospital, Gaborone, Botswana.Method:Two samples were included. Sample one described the epidemiology and included patients admitted during a 2-year period with acute TSCI. Sample two included only patients with TSCI due to RTC.Results:Annual incidence was 13 per million population. Epidemiology of TSCI: 49 patients were included, 71% male, age ranging from 4 to 81 years, 80% ⩽45 years. Tetraplegia was more common than paraplegia (59/41%), and 39% had C1-C4 level of injury. The main cause of TSCI was RTC (68%), followed by assault (16%) and falls (10%). Mortality was 20%, where all, but one, had tetraplegia (18%). Median time from injury to spinal surgery was 12 days, with longer time for women, 16 days compared with 8 for men. Burst tire was the primary cause of RTC resulting in a TSCI, followed by hitting animals on the road. The majority had been passengers and 72% were involved in single crashes.Conclusion:The most common cause for TSCI was RTC, followed by assault. In-hospital mortality was high and the waiting period from the time of accident to spinal surgery was long, especially for women. The aetiology and high mortality of TSCI in Botswana indicate that improvements in roadway safety and medical care may decrease the TSCI incidence and mortality. [ABSTRACT FROM AUTHOR]

Study design:International validation study using self-administered surveys.Objectives:To investigate the utility and reliability of the International Spinal Cord Injury Pain (ISCIP) Classification as used by clinicians.Methods:Seventy-five clinical vignettes (case histories) were prepared by the members of the ISCIP Classification group and assigned to a category by consensus. Vignettes were incorporated into an Internet survey distributed to clinicians. Clinicians were asked, for each vignette, to decide on the number of pain components present and to classify each using the ISCIP Classification.Results:The average respondent had 86% of the questions on the number of pain components correct. The overall correctness in determining whether pain was nociceptive was 79%, whereas the correctness in determining whether pain was neuropathic was 77%. Correctness in determining if pain was musculoskeletal was 84%, whereas for visceral pain, neuropathic at-level spinal cord injury (SCI) and below-level SCI pain it was 85%, 57% and 73%, respectively. Using strict criteria, the overall correctness in determining pain type was 68% (versus an expected 95%), but with maximally relaxed criteria, it increased to 85%.Conclusions:The reliability of use of the ISCIP Classification by clinicians (who received minimal training in its use) using a clinical vignette approach is moderate. Some subtypes of pain proved challenging to classify. The ISCIP should be tested for reliability by applying it to real persons with pain after SCI. Based on the results of this validation process, the instructions accompanying the ISCIP Classification for classifying subtypes of pain have been clarified. [ABSTRACT FROM AUTHOR]

Study Design: A qualitative study with an emergent design using semi-structured interviews in focus groups., Objectives: To explore the expectations, experiences and desires among individuals who are prescribed drugs for spinal cord injury (SCI) neuropathic pain (NP)., Setting: SCI rehabilitation centre., Methods: Eighteen informants with SCI and NP were enrolled. The informants originated from large and small cities in southern Sweden. Data were collected in focus groups consisting of 4-5 individuals in four separate sessions. An emergent design was employed using an interview guide containing open questions. The interviews were transcribed verbatim and data were analyzed according to qualitative content analysis., Results: A model of three themes emerged: "Balancing between pain and side-effects" described the difficult choices the informants had to make between drugs and their unwanted side-effects and pain, "Desiring competence and structure in pain management" described the informants wishes regarding pain management and "From hope to personal solutions" described the process from hope of total pain relief from drugs to the development of personal strategies., Conclusions: There is a great need for improvement of SCI-related neuropathic pain management since recommended drugs are insufficiently effective and accompanied by severe side-effects that impact quality of life but also due to structural limitations and physicians' lack of competence in pain management.

Background: When suffering a spinal cord injury (SCI), the patient and family face numerous challenges regardless of socio-economic level. The stigmatisation of persons with disabilities has been reported, however, reports from Southern Africa are largely lacking., Purpose: To explore the experiences of living with a traumatic SCI in Botswana concerning perceived attitudes, obstacles and challenges., Method: A qualitative approach with semi-structured interviews was conducted. Thirteen community-dwelling persons who have lived with an SCI for at least two years participated., Results: A theoretical model was formed that illustrate the associations between the core category, Self, and the categories Relationships and Society. The model illustrates that personal resources, including a strong identity and a positive attitude, are crucial to the experience of inclusion in the community. A supportive family, a source of income, and faith were strong facilitators, while inaccessibility and devaluing attitudes were barriers. Having a disability led to increased risk of poverty and social exclusion., Conclusion: This study emphasised the importance of personal resources, family support, and improved accessibility to facilitate inclusion in the society. Informants requested legislation to advocate for the rights of persons with disabilities to be respected, with the aim of moving towards an equal accessible society. Implications for Rehabilitation Reclaiming or restructuring one's identity after a SCI is crucial for the person's ability to move on and develop beneficial coping strategies. Support from family and friends, staff and peer support are crucial parts in that process. Spirituality, values, needs and coping strategies vary profoundly among persons sustaining disabling injuries. In striving to optimise care, rehabilitation staff needs to be attentive to the personal resources and preferences to be able to individualise care, encounter, and facilitate transition back to the community. Family members play a crucial part in rehabilitation. It is essential for the patients' well-being and care that they get explicit descriptions of the patient's abilities. Living in a well-adapted home will facilitate well-being, independence, and return to work. Rehabilitation staff needs to focus their efforts on making this successful prior to discharge from hospital.

Purpose: The present purpose was to explore patients' and involved physicians' needs and requests for improving their management of neuropathic pain following spinal cord injury (SCI)., Methods: Sixteen patients with SCI and neuropathic pain, and nine physicians, were interviewed in focus-groups or individual interviews. An emergent design was used and the interviews and analyses were carried out in parallel, making it possible to use and deepen new emerging knowledge. The interviews were transcribed verbatim and processed according to content analysis., Results: A final model with four themes described the results. Three themes covered the current situation: limitations in structure, lack of knowledge and competence, and frustrations. A fourth theme, needs and requests, described suggestions by patients and physicians for future improvements. Suggestions included increased participation, increased patient involvement in the pain rehabilitation process, support in the process of learning to live with pain, implementation of multi-modal pain rehabilitation, and the use of complementary treatments for neuropathic pain., Conclusion: Neuropathic pain following SCI needs to be assessed and treated using a structured, inter-disciplinary, multi-modal rehabilitation approach involving patients in planning and decision-making., Implications for Rehabilitation: For improving SCI neuropathic pain management, there is a great need for individually-tailored management, planned in a dialogue on equal terms between health care and the patient. Patients desire continuity and regularity and the possibility of receiving complementary treatments for SCI neuropathic pain. Access to structured pain rehabilitation is needed. Support and tools need to be provided in the learning-to-live with pain process.

Unlabelled: Pain is a serious consequence of spinal cord injury (SCI). Our aim was to investigate the temporal aspects of different types of pain following traumatic SCI and to determine possible predictors of neuropathic pain. Prospective data on 90 patients were collected at 1, 6, and 12 months after traumatic SCI. The patients completed questionnaires on pain severity, descriptors, and impact and underwent clinical examination with bedside sensory testing. Eighty-eight patients completed the 12-month follow-up. Approximately 80% of patients reported any type of pain at all 3 time points. Neuropathic pain related to SCI increased over time, and musculoskeletal pain decreased slightly, with both being present in 59% of patients at 12 months; other neuropathic pain not related to SCI and visceral pain were present in 1 to 3%. At-level neuropathic pain present at 1 month resolved in 45% and below-level pain resolved in 33%. Early (1 month) sensory hypersensitivity (particularly cold-evoked dysesthesia) was a predictor for the development of below-level, but not at-level, SCI pain at 12 months. In conclusion, the present study demonstrates phenotypical differences between at-level and below-level SCI pain, which is important for future studies aiming to uncover underlying pain mechanisms., Perspective: The finding that early sensory hypersensitivity predicts later onset of below-level central neuropathic pain may help to identify patients at risk of developing neuropathic pain conditions after traumatic spinal cord injury. Information about onset of pain may help to identify different phenotypes in neuropathic pain conditions., (Copyright © 2014 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Nociceptive and neuropathic pain (NP) are common consequences following spinal cord injury (SCI), with large impact on sleep, mood, work, and quality of life. NP affects 40% to 50% of individuals with SCI and is sometimes considered the major problem following SCI. Current treatment recommendations for SCI-NP primarily focus on pharmacological strategies suggesting the use of anticonvulsant and antidepressant drugs, followed by tramadol and opioid medications. Unfortunately, these are only partly successful in relieving pain. Qualitative studies report that individuals with SCI-related long-lasting pain seek alternatives to medication due to the limited efficacy, unwanted side effects, and perceived risk of dependency. They spend time and money searching for additional treatments. Many have learned coping strategies on their own, including various forms of warmth, relaxation, massage, stretching, distraction, and physical activity. Studies indicate that many individuals with SCI are dissatisfied with their pain management and with the information given to them about their pain, and they want to know more about causes and strategies to manage pain. They express a desire to improve communication with their physicians and learn about reliable alternative sources for obtaining information about their pain and pain management. The discrepancy between treatment algorithms and patient expectations is significant. Clinicians will benefit from hearing the patient´s voice.

This study sought to assess burnout and its relation to pain, disability, mood and health-related quality of life in a group of patients with chronic whiplash-associated disorders (WAD). Forty-five patients with chronic WAD (≥3 months) referred to a multidisciplinary rehabilitation centre were included. A questionnaire covering data on background and lifestyle, the Shirom Melamed Burnout Questionnaire, pain intensity, the Neck Disability Index, the Hospital Anxiety and Depression Scale and the EQ-5D was filled in before the first visit to the clinic. A high proportion of burnout as measured using the Shirom Melamed Burnout Questionnaire was found in the patient group (87%). Burnout correlated moderately with present pain intensity, neck disability, depression and health-related quality of life. The results indicate the possible clinical importance of burnout in relation to chronic WAD and the need for further studies including a larger study population and a longitudinal study design.

Purpose: To explore and obtain increased knowledge about (i) strategies and treatments used by individuals with neuropathic pain following spinal cord injury (SCI) for handling long-term pain, and (ii) their experience, needs and expectations of SCI neuropathic pain management., Methods: Qualitative methods with an emergent research design were used. Eighteen informants who suffered from long-term SCI neuropathic pain participated. Data were collected with diaries and thematized research interviews. Content analysis and constant comparison according to grounded theory were used for the analyses., Results: A model with four categories emerged: "Pain is my main problem" explained the impact of pain in the informants' everyday life; "Drugs--the health care solution" described the informants' experience of pain management; "The gap in my meeting with health care" described the discrepancy between what the informants wanted and what health care could offer. "But...this works for me" described treatments and strategies, which the informants found helpful for pain control and pain relief., Conclusion: Neuropathic pain, one of the major problems following SCI, is difficult to treat successfully. To improve treatment outcome, health care needs to listen to, respond to and respect the patient's knowledge, experience and wishes. Future research needs to address treatments that patients find effective.

Objective: The study sought to explore the possibility of using acupuncture and massage therapy for relieving neuropathic pain following spinal cord injury (SCI)., Design: 30 individuals with SCI and neuropathic pain were assigned to treatment of either massage or acupuncture, with 15 individuals in each group. Both groups received treatment twice weekly for 6 weeks. Treatments were evaluated at the end of treatment and 2 months later (follow-up)., Results: Data were analysed on an intention-to-treat basis. Within the groups, ratings of present pain, general pain, pain unpleasantness and coping improved significantly at the end of treatment after acupuncture compared to baseline values, and following massage therapy ratings of pain interference on the Multidimensional Pain Inventory improved. At follow-up no significant improvements were seen. Between-group differences were seen regarding ratings of worst pain intensity at the end of treatment, and regarding pain unpleasantness and coping with pain at follow-up, both in favour of acupuncture. At the end of treatment, eight of the 15 individuals receiving acupuncture and nine receiving massage reported an improvement on the Patient Global Impression of Change Scale, and at follow-up six patients in the acupuncture group and one patient in the massage group still reported a favourable effect from the treatment. Few side effects were reported and neither dropout from the study did this due to adverse events., Conclusion: Neuropathic pain following SCI is often only partially responsive to most interventions. Results from this study indicate, however, that both acupuncture and massage therapy may relieve SCI neuropathic pain. For this reason, larger randomised controlled trials are warranted for assessing the long-term effects of these treatments.

Pain of both neuropathic and nociceptive aetiology is common after spinal cord injury (SCI), and classifying pain is sometimes a challenge. The objective of this study was to test the usefulness of the Swedish version of the screening tools Douleur Neuropathique 4 questions (DN4), the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), the Neuropathic Pain Questionnaire (NPQ), and the painDETECT Questionnaire (PD-Q) in individuals with SCI and pain. A further objective was to define pain descriptors able to discriminate neuropathic pain from nonneuropathic pain. Forty individuals with SCI ≥1 year and pain ≥6 months were examined by a specialised physician and assessed twice using the 4 screening tools. The analysis included tests of reliability (test-retest) and validity (calculation of sensitivity, specificity, and overall agreement), an explorative analysis of the cutoff scores and regression analysis for identifying predictors of diagnostic accuracy. Our results indicate that reliability was good to very good for 3 of the screening tools, DN4, LANSS, and NPQ with a Cohen's kappa coefficient between 0.70 and 1.00. DN4 showed the highest sensitivity (93%), followed by PD-Q (68%), NPQ (50%), and LANSS (36%). LANSS and NPQ demonstrated the highest specificity (100%), followed by PD-Q (83%) and DN4 (75%). Diagnostic accuracy for the tools was for DN4 88%, PD-Q 78%, NPQ 65%, and LANSS 55%. A final model showed that 3 items, hypoesthesia to touch, burning pain, and numbness, could discriminate pain in this cohort of individuals with SCI with a high goodness of fit., (Copyright © 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Study Design: Descriptive, cross-sectional study., Objective: To assess the relationship between spasticity and bone mineral density in the lower extremities in individuals with a motor complete spinal cord injury., Methods: Eighteen individuals, matched for time since injury, gender, and age, were included in the study. Nine men had severe spasticity, and 9 men had spasticity that was either mild or not present. Comparisons regarding bone mineral density were made using dual energy X-ray absorptiometry. Regions of interest measured were total leg, pelvis, femoral neck and total hip. Between-group differences regarding fat and lean tissue were analysed., Results: Background data, such as weight, height, standing and exercising habits, smoking and alcohol use, were similar in both groups. There was no difference between the groups regarding bone mineral density. All of the participants presented with osteoporosis or osteopaenia values at the hips. Participants with severe spasticity had larger muscle volume than those with none or mild spasticity. No correlations between bone mineral density and body composition with age or time since injury were seen., Conclusion: No difference in bone mineral density dependent on spasticity was detected in this study, but all included participants showed osteopaenia or osteoporosis at the hip, but not in full body values. Individuals with severe spasticity had greater muscle mass compared with those with no or mild spasticity.

The aim of the study was to assess the short-term effects of high- and low-frequency (HF and LF, respectively) transcutaneous electrical nerve stimulation (TENS) for neuropathic pain following spinal cord injury (SCI). A total of 24 patients participated in the study. According to the protocol, half of the patients were assigned to HF (80 Hz) and half to LF (burst of 2 Hz) TENS. Patients were instructed to treat themselves three times daily for 2 weeks. After a 2-week wash-out period, patients switched stimulation frequencies and repeated the procedure. Results were calculated on an intent-to-treat basis. No differences between the two modes of stimulation were found. On a group level, no effects on pain intensity ratings or ratings of mood, coping with pain, life satisfaction, sleep quality, or psychosocial consequences of pain were seen. However, 29% of the patients reported a favorable effect from HF and 38% from LF stimulation on a 5-point global pain-relief scale. Six of the patients (25%) were, at their request, prescribed TENS stimulators for further treatment at the end of the study. In conclusion, TENS merits consideration as a com plementary treatment in patients with SCI and neuropathic pain.