A Cognitive Behavioural Therapy Pain Management Programme for Neuropathic Pain Post Spinal Cord Injury: A Feasibility Study Including the Clinician and Patient Perspectives

Special Article – Spinal Cord Injury Rehabilitation

Phys Med Rehabil Int. 2017; 4(3): 1119.

A Cognitive Behavioural Therapy Pain Management Programme for Neuropathic Pain Post Spinal Cord Injury: A Feasibility Study Including the Clinician and Patient Perspectives

Burke D¹*, Lennon O¹, Nolan M², Barry S², Smith E², Maye F², Mc Phillips B², Ní Ghiollain S² and Fullen BM1,3

¹UCD School of Public Health, Physiotherapy and Sports Science, Health Science Centre, University College Dublin, Belfield, Dublin, Ireland

²The Spinal Cord System of Care Team, The National Rehabilitation Hospital Roches town Avenue, Dun Laoighre, County Dublin, Ireland

³UCD Centre for Translational Pain Research, University College Dublin, Belfield, Dublin, Ireland

*Corresponding author: Dearbhla Burke, UCD School of Public Health, Physiotherapy and Sports Science, Health Science Centre, University College Dublin, Belfield, Dublin, Ireland

Received: July 03, 2017; Accepted: July 28, 2017; Published: August 04, 2017


Objective: To evaluate the feasibility of a cognitive behavioural therapy pain management programme for managing neuropathic pain post-spinal cord injury.

Design: A mixed methods prospective feasibility trial.

Setting: A national rehabilitation hospital.

Subjects: Adults with neuropathic pain post-spinal cord injury.

Methods: Following ethical approval, participants were recruited from a spinal cord injury outpatient service. A multi-disciplinary team delivered the programme twice a week over five weeks. Changes in study outcome measures addressing quality of life, mood and sleep indices over three time periods were analysed using Friedman’s test. Differences from baseline to intervention completion and six months follow-up intervals were analysed using Wilcoxon sign-rank test. Significance was set p<0.05. Post-intervention qualitative feedback was obtained from programme participants and the clinicians involved.

Results: Eight participants completed the programme. Significant improvements were noted post-intervention in the psychological domain of the World Health Organisation Quality of Life Bref (Z=-2.120; p=0.03) and the depression score (Z=-2.555; p=0.01) of the Hospital Anxiety and Depression Scale, remaining significantly improved at six months follow-up when compared to baseline (Z=-2.533; p=0.01). Transportation was the main barrier to recruitment. Qualitative feedback highlighted the positive impact for participants in coping with pain. Clinicians noted many positive outcomes of the programme, whilst highlighting health-systems difficulties in implementation.

Conclusions: A cognitive behavioural therapy pain management programme is perceived as beneficial by individuals with neuropathic pain after spinal cord injury, a finding supported by quantitative data analysis. Recruitment barriers to programme delivery indicate that alternate modes of delivery warrant consideration.

Keywords: Spinal cord injury; Cognitive behavioural therapy pain management programme; Neuropathic pain; Chronic pain; Chronic pain selfmanagement


AIS: American Spinal Injury Association Impairment Scale; CBT: Cognitive Behavioural Therapy; HADS: Hospital Anxiety and Depression Scale; HRQoL: Health Related Quality of Life; ln: Line in Transcript; MDT: Multi-disciplinary Team; NP: Neuropathic Pain; NRH: National Rehabilitation Hospital; PMP: Pain Management Programme; PSQI: Pittsburgh Sleep Quality Index; SCI: Spinal Cord Injury; S: Speaker, t1: Pre-Intervention; t2: Post-intervention, t3: Six month follow up; WHOQOL-BREF: World Health Organisation Quality of Life Bref.


Chronic pain, a common sequela after spinal cord injury (SCI) [1], is perceived as a particularly challenging complication to address, along with urinary tract infections, pressure ulcers and spasticity [2,3]. It results in poorer quality of life [4], depression [5] and sleep disturbances [6]. Presentations of nociceptive pain (musculoskeletal, visceral and other) and neuropathic pain (at level, below level and other) may simultaneously co-exist post-injury [7]. However, neuropathic pain (NP) post-SCI is cited as the most severe and disturbing pain [7,8] with a high pooled prevalence of 53% reported [9].

Recent guidelines in NP post-SCI management advocate a multi-disciplinary approach with medical, physical, educational and cognitive-behavioural components, addressing the wider functional and psychological impact [10]. Management, it is proposed, should be patient-centred, goal-directed and functional; treating the patient holistically and including significant others in the process, where appropriate [10]. Whilst the efficacy of multidisciplinary pain management programmes (MDT-PMPs) based on a biopsychosocial approach is well established [11], minimal research addresses chronic pain management post-SCI. A PMP specific to SCI is optimal as adaptations are required to the traditional PMP structure based on participants’ complex needs; personal care routines, reduced activity tolerance and modification of exercise-based components [12]. As per recommendations, this requires expertise in SCI rehabilitation and a dedicated unit for optimal delivery [13]. In addition, coping and adjustment benefits from interaction with peers also experiencing SCI related pain, is significant [14].

Quantitative research dominates the contemporary literature [15-18] addressing the efficacy of CBT-PMPs in adults with SCI chronic pain. Results demonstrate reductions in pain catastrophizing [18], pain interference [15], pain intensity, pain related disability, life satisfaction, anxiety and depression [16-18]. However, pain is a subjective, individual experience, only known to the person who suffers [19]. Despite this, qualitative studies remain under-represented in chronic pain literature [20]. This methodology is gaining increased recognition now in the investigation and understanding of the SCI pain experience from the individual’s perspective, an aspect often in accessible by alternate methods [21,22]. Advancement of chronic pain management furthermore requires documentation of the clinicians’ perspectives [23]. To date qualitative studies detailing the experience of completing a SCI CBT-PMP [17,18] have been limited to short written comments relating to participants’ experience of their CBT-PMP [18] and documenting overall perceptions of the intervention, focusing on programme length and delivery [16,17]. No study has evaluated other stakeholders’ perspectives (e.g. clinicians) on developing and delivering a PMP in a SCI rehabilitation unit.

No recommended timeframe for conducting a CBT-PMP exists as, it is argued, intensity and length should vary based on participants’ health needs and requirements [24]. However, a review of randomised controlled trials of self-management programmes for chronic musculoskeletal pain found longer interventions did not necessarily produce better outcomes [25]. Previous CBT-PMPs for SCI pain ranged in length from eight [18] to ten weeks [15,17,26], with programme contact hours ranging from 33 [16] to 50 hours [15,17]. A shorter, condensed CBT-PMP has yet to be evaluated and warrants consideration given recruitment issues [17,18], reduced activity tolerance, mobility restrictions and inherent transport barriers [12,15] reported in previous studies of CBT-PMPs in SCI. Hence this study aims to establish the feasibility and efficacy of a shorter, more intensive CBT-PMP in subjects with chronic NP post-SCI and garner broad stakeholder perspectives that include participants’ experience as well as clinicians’ perspectives relating to programme development and delivery.


Study design

This mixed methods prospective feasibility trial involved community dwelling adults with diagnosed NP post-SCI. Phase 1 involved participants attending a SCI tailored CBT-PMP twice a week for five weeks. Quantitative outcome measures (pain, quality of life, mood, and sleep indices) were collected at baseline, post-intervention and six months post CBT-PMP completion. In Phase 2 qualitative data (semi-structured telephone interviews) were collected relating to individuals’ experiences of participating in the programme. A focus group of clinicians involved in the design and delivery of the programme was also conducted to explore their experiences of devising and rolling out the CBT-PMP and to gain insights for future programme sustainability.

Recruitment and inclusion criteria

Following ethical approval from the National Rehabilitation Hospital (NRH) Ethics Committee, participants with a documented NP diagnosis were recruited through the NRH outpatient clinic. This is the only dedicated clinic for community dwelling adults with a SCI in the Republic of Ireland. Written and informed consent was obtained from each participant.

Potential participants were sent information about the study (Phase 1 and Phase 2). Inclusion criteria in phase 1 included SCI American Spinal Injury Association Impairment Scale (AIS) score A-C [27], discharge from acute hospital and rehabilitation services, diagnosis of chronic NP (pain greater than three months, confirmed by a rehabilitation medicine consultant), over 18 years of age, with fluent English (verbal and written) and the ability to attend a five week programme in Dublin.

Exclusion criteria included AIS D-E, acute injury under specialist medical care, any ongoing medico-legal cases and any confounding co-morbidities including cancer, unstable angina, uncontrolled cardiac arrhythmias, severe aortic stenosis, acute systemic infection accompanied by fever, systemic or inflammatory diseases, substance abuse, significant mental health issues or inability to provide informed consent. Following screening, a consent form and battery of validated questionnaires were sent by post, one week prior to programme commencement. All clinicians involved in the planning and delivery of the programme were invited to participate in a focus group following programme completion.

Phase 1: The intervention

The CBT-PMP ran twice weekly for five weeks (10am-14:45pm) with 3.5 daily contact hours. The programme was adapted from the empirically tested Ulysses CBT-PMP by SCI rehabilitation specialists from medicine, clinical psychology, physiotherapy, occupational therapy, dietetics, social work, nursing and clinicians involved in the Ulysses CBT-PMP [28], guided by Perry et al. [12]. Adaptations of the Ulysses CBT-PMP [28] facilitated the anticipated requirements of individuals with SCI. Weekly sessions were reduced from three days a week to two days per week and length of delivery increased from four to five weeks. The exercise component was modified to reflect current best practice as delivered by the NRH with exercises adapted to suit the individual needs of the participants with varying SCI presentations. Sessions involving goal setting placed less emphasis on reduction of mobility aid use and return to full time employment; instead participants were encouraged to pursue goals relevant and applicable to their life after SCI. Pain education sessions were modified to include information on SCI pain mechanisms and classification. Less importance was placed on the reduction of pain medication use throughout the programme and as an alternative, education was provided regarding medications recommended in the management of SCI pain, similar to Perry et al. [12]. Participants enrolled in the trial were asked to refrain from altering current medications for the duration of the CBT-PMP.

The CBT-PMP content, summarised in Table 1, was based on principles of Fordyce [29] and Turk [30] and incorporated operant and cognitive behavioural principles. It comprised daily group psychology sessions focusing on CBT principles and using cognitive techniques to identify unhelpful and unrealistic thoughts and beliefs related to pain and to challenge and change them. Daily group relaxation sessions were completed in addition to gym-based physiotherapy sessions with a patient-driven progressive programme modified for each individual’s ability. Goal setting by participants was encouraged throughout the programme to aid the incorporation of learned CBT techniques into daily life. Three key worker sessions took place over the course of the programme where participants had the opportunity to meet individually with an allied healthcare professional. These sessions explored in more detail goal setting and personal issues surrounding NP that the participant may not have wished to share in a group setting.