P - NEUROPATHIC PAIN Tools & Resources

Delivery of care for neuropathic pain in individuals with SCI should be:

1. coordinated
2. interprofessional
3. timely
4. patient-centred
5. using a biopsychosocial framework
6. evidence-based.

Numerous factors affect the presentation of chronic pain, including psychosocial and environmental factors. Conversely, chronic pain can significantly affect function, mood, and social relationships. Therefore, management of chronic pain after SCI in patients with complex presentations requires an interprofessional or interdisciplinary team approach that incorporates medical, physical, educational and cognitive-behavioural components. Communication between healthcare providers, between healthcare providers and administrators, and between healthcare providers and the patient is a central tenet of coordination of care services.

A biopsychosocial framework should guide the structure of a program and individual care plans. This model considers the interplay between physiology, psychology and social factors on the pain experience that affects neuropathic pain outcomes for individuals with SCI.

As proposed by Strauss et al., evidence-based decisions are essential to advancing practice, with priority given to SCI-specific guidelines and studies.

An individual with SCI and either:

1. new-onset or worsening spinal cord injury-related neuropathic pain, and/or,
2. ongoing pain that is difficult to manage and/or,
3. dissatisfaction with their current pain management protocol,

should be screened and assessed by a clinician with experience in managing individuals with SCI. (SYS CARE 2016, p.S25; Level C)

It is essential to involve clinicians with SCI experience when working with patients who have SCI-related neuropathic pain, who present with any of the conditions outlined in Recommendation V.4.2. A clinician with SCI experience can recommend relevant referrals, assessments, investigations, and treatment steps as appropriate. If necessary, on the basis of the results of the assessment, then this individual can act as a gatekeeper to team-based care for SCI-related neuropathic pain. If a diagnostic workup is required to determine the etiology or triggers of neuropathic pain after SCI, it is essential to involve the rehabilitation medicine specialist to ensure that relevant conditions are considered, and that appropriate investigations are implemented.

Multidisciplinary care coordinated through an SCI rehabilitation team is recommended when significant functional impacts and/or significant psychological comorbidity factors resulting from neuropathic pain need to be addressed. Further, a detailed plan of care shared among healthcare providers needs to be implemented across primary, secondary, and tertiary services. (SYS CARE 2016, p.S25; Level C)

It is important to recognize that pain management strategies should also address the functional and psychological impacts of pain, as current treatments may not eliminate pain or even reduce it effectively. As patients should expect to live with some degree of pain and discomfort, it is essential that they learn to minimize the impact of these symptoms on their daily lives. Generally, delivery of comprehensive care through an SCI rehabilitation team has been shown to be central to improving SCI outcomes. Access to such a team is therefore essential to managing complex functional impacts and/or psychological comorbidity more effectively. Currently, the implementation of specialized treatments may require access to a specialized pain clinic. Open communication and coordination between pain specialists and the SCI specialist team is required. Moving forward, we recommend that, given the unique needs of the SCI population, these treatment options be available at SCI-specific rehabilitation facilities.

As patient needs evolve, team members may change over time. The team approach to patient care can improve access to care, quality of care, and cost-effectiveness. The team approach is effective in increasing diagnostic accuracy and timeliness of treatment, which can improve health outcomes and patient satisfaction while increasing resource utilization efficiency and job satisfaction for clinicians. In addition, the team approach can streamline communication with patients and families. It is also important to consider the role of telemedicine, e-consults, and other forms of distance communication to allow staff from specialized rehabilitation centers to continue to provide oversight when travel is a barrier to optimal care delivery, such as may occur for patients in rural areas.

The multidisciplinary team should develop a detailed and integrated rehabilitation care plan that includes a focus on neuropathic pain in alignment with Accreditation Canada 2014 standards (https://accreditation.ca/spinal-cord-injury-rehabilitation-services). Multidisciplinary care should take a patient-centred, goal-directed, holistic, and functional approach to pain management that incorporates the caregiver and/or significant other in the care plan. Members of the multidisciplinary team should include the various rehabilitation disciplines such as physiatry, physiotherapy, occupational therapy, psychology, social work, nursing, and other professionals as needed.

An individual with neuropathic pain as a result of SCI should be discharged from specialized care when three conditions are met:

1. a stable plateau has been reached in pain severity and/or pain-related functional status
2. an ongoing plan linked to resources and provider follow-up is in place
3. self-management techniques have been taught.

The goal at discharge from specialized care should be stable pain severity and optimized function relative to an individual’s ongoing pain severity. Complete alleviation of pain is not usually a realistic outcome. A stable plateau may be considered to have been reached when the care providers and the patient feel maximal gains have been reached, given the available time and resources, in managing pain and its impact on everyday functioning. Periodic reassessments by specialized care providers may be appropriate after discharge to ensure the stability of pain management.

The goal of self-management education is to equip the patient to manage pain as independently as possible.

The SCI rehabilitation team should engage in continuous quality improvement, including evaluation and feedback efforts regarding their pain management practices based on patient outcomes. The plan, which is part of the ongoing care for neuropathic pain management, must be available to the patient before discharge from rehabilitation, and the patient must be educated about its elements. The plan must also be provided to any post-discharge care providers at discharge and especially to the provider assuming primary management of the patient. Useful items to include in the discharge plan, depending on the complexity of the case and the team members involved in care, are current medication, a medication titration plan, a plan for future pain management, nonpharmacologic treatment modalities, scheduled ongoing rehabilitation visits, and suggestions for the timing of follow-up and re-referral to rehabilitation. As much as possible, a discharge plan should also remove barriers to accessing services and identify appropriate community resources for each patient. It is often possible to identify suitable resources by working with partner organizations and allied services.

It is essential to integrate the principles of self-management into the discharge plan and patient education, to support the maintenance of a patient’s function and stability of pain management after discharge. Self-management interventions commonly involve psychoeducation to develop or improve self-efficacy skills in goal setting, problem-solving, management of psychological consequences, medication management, symptom management, social support, and communication.

Techniques should be:

1. demonstrable or actionable by the individual,
2. matched to the individual’s abilities,
3. linked to further community support.

Evaluation of practice supports accountability and improvement. The subjective nature of pain and the challenging nature of successful pain management make continuous quality improvement critical to ensuring that the individual’s needs continue to be met and that resources are used appropriately. Essential elements of a quality improvement program are process and outcome indicators to demonstrate the status of practice change. Process indicators, such as monitoring measure implementation, should include intent and by target. Outcome indicators, such as a reduction in the intensity of an individual’s pain over time, should be measured using the International Spinal Cord Injury Pain Basic Data Set element on pain intensity to accurately assess change produced by practice activities.