About the Author(s)

Mokgadi K. Mashola Email symbol
Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

Elzette Korkie symbol
Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

Diphale J. Mothabeng symbol
Department of Physiotherapy, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa


Mashola MK, Korkie E, Mothabeng DJ. Development of a pain self-management intervention framework for people with spinal cord injury, Afr J Prm Health Care Fam Med. 2023;15(1), a4039. https://doi.org/10.4102/phcfm.v15i1.4039

Research Project Registration:

Project Number: GP201806005

Original Research

Development of a pain self-management intervention framework for people with spinal cord injury

Mokgadi K. Mashola, Elzette Korkie, Diphale J. Mothabeng

Received: 15 Feb. 2023; Accepted: 15 Aug. 2023; Published: 26 Oct. 2023

Copyright: © 2023. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Background: Pain is the most common reason for medical visits to primary health care practitioners. Pain self-management interventions are encouraged and there is no known self-management intervention framework available that clinicians and people with spinal cord injury (PWSCI) can use to guide treatment selection.

Aim: This study aimed to develop a pain self-management intervention framework for PWSCI.

Setting: Online and facilitated in Gauteng, South Africa.

Methods: A three-round modified e-Delphi method was used to reach an 80% consensus among a 21-expert panel. Fifty-nine interventions were distributed via REDCap and a final online audio meeting was held to either include or exclude interventions in the final framework. SPSS v27 was used to analyse descriptive data and content analysis was used for qualitative responses.

Results: The final developed pain self-management framework consists of 56 interventions and includes interventions from multiple health professions to encompass medical, psychological, therapeutic and social interventions. Interventions are also specified for nociceptive and/or neuropathic pain and grouped according to the biopsychosocial model.

Conclusion: The interprofessional framework may be used as a guideline for PWSCI to alleviate pain, as well as assist health professionals in clinical decision-making, by providing them with the freedom to choose acceptable and adequate interventions that may be appropriate to treat the affected individual’s pain.

Contribution: Pain management is a basic need at the primary healthcare level and PWSCI need access to the broad range of interventions available to manage their pain. The framework highlights the variety of appropriate interventions to guide both health professionals and PWSCI with pain relief options.

Keywords: modified e-Delphi; pain; self-management; spinal cord injury; treatment.


A spinal cord injury (SCI) results in partial or complete loss of motor and/or sensory functions below the level of injury and results in common secondary health conditions (SHCs), including pain, pressure ulcers as well as urinary and bowel complications.1,2 Secondary health conditions are debilitating and worsen the experience of disability for people with spinal cord injury (PWSCI) by negatively influencing their dignity and independence.3 The SHCs also cause PWSCI to consult more with health professionals and cause multiple readmissions to the hospital.4,5 Approximately half to two-thirds of PWSCI experience pain, which is an unpleasant sensory and emotional experience that is associated with either actual or potential tissue damage.6,7 Pain often commences within the initial 6 months after SCI, with the possibility of being aggravated over time.8 The experience and perception of pain may be intense and reported as severe to extreme, negatively affecting health satisfaction and interfering with activities of daily living.9,10 The multifactorial pattern of pain ultimately affects how patients react to pain and respond to pain management. In addition, the different underlying mechanisms of pain further challenge pain management.11 For example, pain management can be further complicated by a variety of emotional, behavioural and social factors that can negatively affect the experience of pain.12 The severity of pain is influenced by various factors such as genetics, comorbidities, current psychological state, prior experience of pain and socioeconomic circumstances,13 and treatment is rarely aimed at all associated factors of pain, resulting in ineffective treatment strategies.14 Despite the challenges, management of pain is essential, and without intervention, PWSCI may experience additional losses in function and community mobility.15

Pain management interventions following SCI include task modifications, therapeutic treatments, and pharmacological and surgical options. Therapeutic interventions such as physiotherapy are recommended as first-line treatment16 with a wide range of therapeutic interventions such as thermotherapy, electrotherapy, massage and exercises.17 Despite recommendations, pharmacological treatment of pain remains the mainstream choice of pain management in the spinal cord population. However, PWSCI still report that significant pain relief is difficult to achieve, with pharmacological treatments providing very minimal pain relief.18 Corticosteroid injections and surgical interventions (such as rotator cuff repairs in the shoulder) are only considered as a last resort to manage severe pain. Surgical intervention is often unsuccessful in PWSCI because of the extended 6-week period of rest required after surgery.14 The strict protocols post-surgery hinder independence in wheelchair use19 and create a high risk of developing potential SHCs such as pressure ulcers when on bed rest.

Pain is the most common reason for medical visits to primary health care practitioners,20 and frequent visits for pain-relieving interventions may not be logistically and financially feasible, especially for affected individuals from low-income households.21 Coupled with findings that self-management tasks and skills incorporated into daily life reduce SHCs, it is unsurprising that self-management programmes are steadily being more common.22,23 Furthermore, literature has highlighted the need for increased self-management efforts for PWSCI to reduce overall SHCs.24 Self-management is defined as the ‘individual’s ability to manage symptoms, treatment, physical and psychosocial consequence and lifestyle changes inherent in living with a chronic condition (p. 178).’25 Self-management interventions may refer to a single or combination of approaches that PWSCI can learn (or be taught by any health professional) to enable them with the skills to reduce the impact of the pain on their everyday life.26 Behaviour therapy, relaxation techniques, stretching and exercises are among the wide variety of self-management techniques identified to relieve pain.27 Self-management also includes the ability of affected individuals to monitor their pain condition and their behavioural, cognitive and emotional responses.28 Self-management includes problem-solving, decision-making, using resources, communicating with health professionals and taking action when needed.29 People with SCI must have self-management programmes targeted at all three categories because of the complexity of SCI, which often present with multiple chronic conditions.30

Self-management of chronic pain requires that affected individuals distinguish themselves from the pain they experience so that they do not define themselves by their pain.31 Barriers to self-management include the overwhelming effort to manage pain, unsupportive family members or health professionals, and limited problem-solving abilities.31,32 There is a need for increased self-management efforts by both healthcare providers and PWSCI to reduce SHCs in PWSCI,33 and this study aimed to develop a guided pain self-management intervention framework from the perspective of HCPs working with PWSCI.

Research methods and design

Study design

This study utilised a qualitative approach and a Delphi design to obtain the most reliable consensus from a group of experts by using surveys to receive controlled feedback on their opinions, especially when there is little or no definitive evidence on the subject.34,35,36 A Delphi design involves an iterative process that is useful in gathering subjective information from experts working in the field of interest and there are variations on the classic Delphi method.37 The classic Delphi is modified by presenting the experts with a predetermined list of interventions that may be used to manage the pain instead of the experts determining the list, hence the term ‘modified Delphi’. The predetermined list comprises interventions to manage pain and not specifically self-management interventions, as the experts needed to select the interventions that would be appropriate for self-management. The predetermined list of interventions was derived from phase 2 of a mixed-method study by the authors and published literature. Phase 2 explored the experience of pain by PWSCI and the coping strategies they used to manage their pain, following guidance from the first quantitative phase. The first phase found that 85% of PWSCI reported pain with a severity of 6.7/10.38 This study is the third phase of this mixed-method study.39 The approach is referred to as a ‘modified e-Delphi’ design in this study because all three rounds of the modified Delphi were conducted online.37 The modified e-Delphi study was conducted and informed by a predefined and published protocol39 and is reported as per the Conducting and Reporting Delphi Studies (CREDES) recommendations.40


This study was conducted online: REDCap for the first two rounds and Microsoft Teams for the third and final round.

Study population and sampling strategy

Healthcare professional experts were identified from a variety of different professional backgrounds in the field of SCI and/or pain management in academia and clinical practice. The experts were identified from their global contribution to the following associations: International Spinal Cord Society, Africa Spinal Cord Injury Network, Southern African Spinal Cord Association, and PainSA. Experts in academia needed to be in a possession of a master’s degree and experts in clinical practice had to have at least 10 years of experience in their respective fields. Sixty-four experts were purposefully sampled and invited via email to participate in the study. A detailed information sheet explaining the study aims, process and informed consent was emailed to the experts before participating in the study.

Data collection procedure

Figure 1 shows the procedure of this modified e-Delphi study. A pilot study with the same procedure as planned for the main study was conducted, as guided by Clibbens et al.41 Two experts meeting the inclusion criteria were included in the pilot study (one in the SCI field and the other in the pain management field). The pilot study was conducted over 1 week; feedback was received and collated and modifications were implemented before commencing with the main study. Results from the pilot study were not included in the main results as changes were made, and the two experts who participated in the pilot study were not included in the main study, but remained experts for the round two pilot study.

FIGURE 1: The procedure of this modified e-Delphi study.

Round one

REDCap was used to construct and distribute the predetermined interventions. Participants were given 2 weeks to complete the survey and those who did not respond by the end of the 2 weeks were removed from the study. Reminders were sent at the end of the first week and 2 days before the deadline. The participants were given the option to select ‘agree’, ‘disagree’ or ‘do not know’ for each intervention as guided by Eubank et al.34 Participants were required to give reasons for their selection in the text box provided and also had the option of adding comments and extra interventions that were not on the predetermined list. The third week was allocated for data analysis. The items were analysed descriptively using SPSS v27 to determine the 80% consensus34 and content analysis was used to analyse the data from the free text boxes. Interventions that did not receive consensus were redistributed in round two without giving participants feedback on how the items were scored to maintain impartiality.

Round two

Feedback from experts in the comment sections recommended that the researchers consider giving more information over and above the descriptions provided for each intervention. Therefore, one moderate-to-high level of evidence article was included per intervention in round two. Medline (PubMed) was used to search for each intervention that was redistributed in round two. In this round, participants had to either ‘agree’ or ‘disagree’ only; thus the ‘do not know’ option was removed to receive firm decisions from the participants. Similar to the previous round, the participants were also required to give reasons for their selection in the text box provided. A pilot study was also conducted for round two by the same experts who were involved in the initial pilot study. Comments and feedback from this pilot study were collated and changes to the round two survey were carried out. The pilot study results were also not included in the main study because some changes were required for the main study and the experts involved in the pilot study did not participate in round two. The survey for round two was also distributed via REDCap and conducted over 2 weeks. Reminders were sent as per round one and non-responders were removed from the study. The same steps as in round one were followed to analyse the data.

Round three

The aim of round three was to discuss the interventions that did not reach 80% agreement to include or exclude from the final framework. Participants who responded in round two were sent a ‘Doodle poll’ link to select their preferred time slot over 14 days to conduct round three via Microsoft Teams, and were not anonymous. The date and time when most of the experts across different professions were available were chosen as the day of the meeting. Interventions that did not reach the 80% consensus in round two were redistributed in round three and there was expert interaction to exchange important information and reasons for disagreements were clarified. Previous interventions that met the 80% consensus in round two but received objections in round three were discussed and removed following unanimous decisions to do so. Only the interventions that reached 80% consensus at the end of this round were added to the final framework. The consensus was decided by a vote of hands, where the participants typed a ‘thumbs up or thumbs down’ in the chat and the lead author counted the votes for each intervention. The final list of interventions was grouped for neuropathic and/or nociceptive pain and also according to the biological, psychological and social components of the biopsychosocial model of care.

Data analysis

The SPSS v27 was used to descriptively analyse the participants’ demographic information, as well as the items to determine consensus. Data were reported in frequencies, percentages, means and standard deviations. Qualitative data were analysed using content analysis as guided by Erlingsson and Brysiewicz.42 Apart from maintaining consensus in all the rounds, rigour was also controlled in the last round by giving the experts the opportunity to revise the findings of the two rounds, using consensus, to determine which responses were appropriate.43 Furthermore, the authors kept a methodological journal during the study to document the major decisions and the interventions that sparked debates.

Ethical considerations

This modified e-Delphi study is the third phase of the mixed-method study that is registered with the South African National Health Research Database (reference GP201806005) and received ethical approval from the Faculty of Health Sciences Research Ethics Committee of the University of the Pretoria, South Africa (approval number 125/2018). Written informed consent was obtained from all the participants in this study, including consent for the third round to be audio-recorded. Furthermore, participants’ names are not used to ensure confidentiality.


Participants’ demographic information

Twenty-two participants from South Africa, Sweden and Canada accepted the invitation and 21 participants completed the survey and were included in the study. The mean age of the participants was 42.55 years (s.d. = 10.53) and the mean year practicing in their professions in their highest qualification was 11.09 years (s.d. = 10.47). The majority of the participants had a master’s degree (n = 10, 45.5%), practiced in the clinical setting (n = 12, 54.6%) and were mainly physiotherapists (n = 8, 36.4%) as shown in Table 1.

TABLE 1: Participants’ information (n = 21).
e-Delphi information
Round one

Table 2 illustrates the descriptive statistics of the predetermined items, with the first column specifying where the interventions were sourced from. Twenty-one participants completed round one (95.5% response rate) and one participant did not complete the survey. The consensus was achieved with 80% agreement for 34 interventions out of the original 59. Twenty-five interventions, therefore, did not achieve consensus in this round.

TABLE 2: Round one descriptive statistics of the items (59 interventions).

Tourniquet application, surgery and recreational cannabis had the majority of disagreements to be included in the final framework; however, the disagreements did not reach 80% consensus (61.9%, 47.6% and 61.9%, respectively). Most of the participants did not know whether to include self-hypnosis (47.6%), Thai massage (52.4%), Maitland and Mulligan joint mobilisations (42.9% and 57.1%, respectively) and electrotherapy to non-innervated areas (38.1%). Although not in the majority, pharmacological interventions saw many participants not knowing whether to include the specific drug groups, namely, anticonvulsants (42.9%), serotonin-selective reuptake inhibitors (SSRI) (42.9%) and serotonin-norepinephrine reuptake inhibitors (SNRI) (47.6%), antidepressants, as well as anxiolytics (42.9%).

Following the inductive thematic analysis of round 1, three themes were identified. The qualitative results support the quantitative results as it was found that most ‘do not know’ responses were because of concerns about medications that need to be prescribed appropriately, interventions falling outside of one’s scope, and more information necessary before decisions could be made about including or excluding interventions from the framework. The thematic analysis guided the researchers to include the literature in the second round.

Theme one: Medication should be appropriately prescribed

There was a general concern with medication dependency and organ function with prolonged use, and participants reported that there must be the correct use of the medication with consideration of side effects:

‘Opioids are addictive and may lead to poor quality of life in the long run.’ (Participant 16, 46 years, MOccTher)

‘Medication is useful when used appropriately and under the guidance of a clinician or medical practitioner.’ (Participant 4, 47 years, MSc Occupational Therapy)

Theme two: Beyond the scope of practice

There was a general unfamiliarity with certain interventions that fell outside one’s scope of practice:

‘Physiotherapists do not prescribe drugs.’ (Participant 5, 59 years, PhD Physio)

‘I’m not aware of this for pain management.’ (Participant 8, 28 years, BSc OT)

Theme three: There is a need for more information on the interventions

On some interventions that were not as popular as others (e.g. body awareness training), participants commented they needed to familiarise themselves with some of the interventions:

‘I would need to do more research in this regard.’ (Participant 2, 29 years, BSc Physio)

‘I am not familiar with this technique.’ (Participant 1, 34 years, MBCHB)

Ten more pain self-management interventions were added to round two following the content analysis of suggestions from the participants and are shown in Table 3.

TABLE 3: Round two descriptive statistics of the items.
Round two

Sixteen participants completed round two (76.2% response rate) and five participants did not complete the survey. The consensus was achieved with 80% agreement for 22 out of the 35 total interventions. Thirteen interventions, therefore, did not achieve consensus in this round as shown in Table 344,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75. Six of the 10 new interventions that were included in round two reached a consensus. Of the initial interventions, tourniquet application, surgery and recreational cannabis still showed disagreement to be included (75%, 43.8% and 68.8%, respectively) and 10 interventions (40%) from the original 25-item list did not reach consensus. Table 3 also depicts the references of the articles used in this round and the respective level of evidence (LOE) as guided by the Johns Hopkins Nursing Evidence-Based Practice.76

Two themes were identified following the inductive thematic analysis of round two. Concerns were raised about side effects and the availability of the equipment that would be necessary for some of the interventions.

Theme one: Adverse effects are too risky

Although consensus was not reached to exclude some interventions from the framework, most of the participants felt strongly about interventions they deemed unsafe and untested:

‘This is such an esoteric technique that requires training that I think it is totally impractical to be accepted as a mainstream treatment for post-SCI pain.’ (Participant 16, 46 years, MOccTher)

‘Sounds as though this method is cost-effective and easy to use but research does not prove the effect of this therapy approach.’ (Participant 1, 34 years, MBCHB)

‘This technique is high risk for patients with impaired sensation and are already potentially at high risk for circulatory disorders.’ (Participant 11, 53 years, MMed(Ortho))

Theme two: Availability of resources

Participants expressed concerns regarding the availability of some interventions, especially for patients in low-resourced areas:

‘This modality is not widely available in the South African setting and is not funded. Although I feel it would be helpful in reality very few patients could receive this.’ (Participant 16, 46 years, MOccTher)

Round three

Thirteen interventions that did not reach consensus in round two were redistributed and discussed in round three via an audio conference meeting on Microsoft Teams. Fourteen participants responded to the ‘Doodle Poll’ and nine participants were available at one time slot and subsequently accepted the meeting invite. The nine participants included four physiotherapists, three occupational therapists and two medical doctors. One physiotherapist did not join the meeting and a final eight experts (all from the medical fratenity) participated in round three (50% response rate from round two). The consensus was achieved with 80% agreement for all 13 interventions that did not meet the consensus in round two to be excluded from the final framework as shown in Table 4. The meeting was conducted in English and was recorded and transcribed.

TABLE 4: Round three descriptive statistics of the items.

Table 5 depicts the consensus to specify the type of pain for each item. Following robust discussion, Thai massage and auto-assisted Maitland joint mobilisations, which both received 81.3% agreement in round two to include in the framework, were excluded following a unanimous decision. The reasons cited by the experts included that masseuses providing Thai massage were not medically trained and that Maitland techniques often need a therapist to effectively provide the necessary pain relief.

TABLE 5: Developed guided pain self-management intervention framework (56 interventions).

The general agreement by the participants was that some of the interventions need to be adequately taught to PWSCI by qualified health professionals where applicable. Furthermore, participants emphasised the following interventions:

  • All prescribed medication: The source of pain must be considered and the prescription must be appropriate for optimum pain relief and avoidance of dependency.
  • Psychoeducational management: Emphasis was placed more on neuropathic pain than nociceptive pain.
  • Active stretches of innervated areas: Emphasis was placed more on nociceptive pain.
  • Transcutaneous electrical nerve stimulation (TENS): To be applied with caution and individuals must be taught the correct parameters before application.

Figure 2 illustrates the final guided pain self-management intervention framework as per the biopsychosocial model.

FIGURE 2: The biopsychosocial aspects of the developed guided pain self-management intervention framework.


This study derived an expert consensus list of interventions to include in a guided pain self-management intervention framework for PWSCI. The overall response rate was 73.9% across the three rounds, which is slightly lower than the 80% overall response rate from studies reviewed by Gargon et al.85 Literature has found that a higher number of items tend to result in lower response rates in subsequent rounds and vigorous strategies, such that up to four reminders are necessary for higher response rates.77,78

The final framework consists of 56 interventions that are appropriate for nociceptive and/or neuropathic pain and span across the different domains of the biopsychosocial model. Lifestyle modification was the only intervention that received unanimous agreement from experts in the first round, suggesting that the need for individual-based management may be more important than medical, psychological or therapeutic interventions in isolation. Lifestyle changes are person-specific and may include changes to alcohol use, smoking, as well as leisure-time physical activity, and diet among others. Excessive alcohol use is associated with increased pain severity and interference,79 while cigarette smoking is found to have both causal and reciprocal effects on pain in the general population80 and worsening pain in PWSCI.81 Increased leisure-time physical activity as well as physical activity targeted at weight loss is associated with decreased pain levels and improved health satisfaction in PWSCI.82,83,84 Lifestyle changes can be achieved by using self-management programmes that focus on behaviour change.85

The majority of the psychological interventions reached ≥ 90% agreement including cognitive behavioural therapy (CBT), mindfulness, psychological control techniques and psychological educational management, which are some of the most common self-management interventions.27,32 Although included in the final framework, many of the pharmacological interventions only reached consensus in the second round following the inclusion of literature evidence. This is unsurprising as the panel of experts only consisted of one pharmacist and four medical doctors. Tricyclic antidepressants and NSAIDs were the only groups of medications that were agreed on in the first round. Although this may seem as if the experts did not, at first glance, agree for all groups of medications to be part of self-management, likely, tricyclic antidepressants and NSAIDS are still known by the experts to be first-line pharmacological interventions for neuropathic and nociceptive pain, respectively. Although NSAIDs remain appropriate for nociceptive pain, anticonvulsants such as pregabalin are now the first-line medication for neuropathic pain.85,86 The content analysis identified that medication should be appropriately prescribed and will only be useful when used as prescribed and only under the guidance of a health professional. Inappropriate medication prescription is a public health concern, especially in vulnerable groups such as the elderly and people with disabilities.87 Prescribers should, therefore, take care to not only prescribe appropriately but also address the adverse outcomes of prescribing medication.88 Pain medication misuse is common in PWSCI and the risk is greater for those with increased pain severity.89 Prescribers need to also consider alternative interventions to reduce the potentially catastrophic consequences of pain medication misuse (such as death from overdosing).

Although the interventions that were eventually excluded did not reach a consensus to be excluded from round one, there was consistent agreement among experts to exclude tourniquet application, surgery, recreational cannabis and electrotherapy in non-innervated areas. There was a major safety concern when PWSCI need to be performing some interventions that were suitable for self-management without supervision. Indeed, maintaining control over one’s care is a facilitator in self-management;33 however, techniques need to be performed correctly to not only be effective but also to prevent injury. The inclusion of the tourniquet application was a surprise to many experts, as this is a known intervention to stop blood supply and can be dangerous in individuals with already poor blood circulation and impaired sensation. Tourniquets are only applied during surgery of the limbs and are already known for possible nerve, muscle and skin injury.90 One person with SCI used this technique to ease neuropathic pain below the level of injury. A panel discussion by Evans et al.91 concluded that blood flow restriction training was safe and effective for improved skeletal muscle strength, when performed by a skilled health professional. However, the potential for pain relief needs further research, including its use as a self-management technique because of the potential adverse effects. The need to achieve pain relief, coupled with other factors such as barriers to accessing health facilities, leads PWSCI to attempt anything, including recreational cannabis.92 Although there is some effectiveness shown with the use of cannabis in PWSCI,92,93 cannabis use is still understudied, and inclusion of medicinal cannabis in this framework is performed on the condition that the country of use has legalised it and has been prescribed by a health professional. Experts in this study pointed out that some of the interventions are not widely available in the local context. Although some interventions have proven effective in other countries, it may not always be implementable in another country such as South Africa.94 This may be because of the various factors such as differences in the communities, attitudes and beliefs, or financial accessibility. The interventions were therefore included on the premise that they would be available for PWSCI in the local context.

By including the ‘do not know’ option in round one, the authors were able to determine that although healthcare professionals work within a multidisciplinary approach in SCI rehabilitation, there is inadequate information known about interprofessional pain management techniques. This may pose a problem where advocacy is needed for a patient regarding adverse effects picked up by another professional. For example, although physiotherapists in South Africa do not prescribe drugs, knowing the effects of the drug assists in knowing what to expect during therapy or when certain self-techniques are prescribed. A medical practitioner would not know how to adequately advise a patient who is not responding well to non-medical interventions. Therefore, appropriate referrals will need to be made for a holistic treatment for PWSCI with pain to improve HCP practice. The onus rests on the HCPs to increase their knowledge of the various interventions available and expertise in managing pain using other techniques within their scope of practice. Although more difficult to establish, an interdisciplinary approach has been shown to increase the effectiveness of pain management programmes95,96 and could be a consideration for PWSCI.

Strengths and limitations

The limitation of a Delphi study is that the expert opinions are often based on either their experiences or biased. However, the results of Delphi studies form an important foundation for decisions that are relevant for clinical practice, especially because clinical guidelines are often grounded on expert opinions and experiences.40 This study had a high response rate in the first two rounds, losing only 4.5% of the experts in round one and 23.8% in round two. There was a 50% response rate in round three and this attrition rate may be because of the online meeting being held during working hours. All experts were employed and availability would not be possible for some experts despite the wide range of timelines over the 14 days given to them. Furthermore, experts resided in different countries and had up to 9 h of the time difference, further making some experts unavailable for certain time slots. Hasson et al.97 have reported on attrition because of the length of commitment as the rounds progressed. It was initially planned for 7–14 experts39 but opted to invite more experts in anticipation of a possible decline in the response rate as the rounds progressed. Although the study commenced with an expert from each profession involved in SCI care, the participants were not evenly distributed across the different professions, resulting in some professions not being represented in the final round because of attrition or unavailability.

Following comments from participants that more information was needed on certain interventions, articles were included on all the interventions and the participants were encouraged to read up on the interventions themselves. Round two was piloted to ensure credibility; however, the authors take into consideration that the inclusion of the literature may have not prevented bias, because the participants were not expected to make their own research before participating in this study. Despite the inclusion of the literature in round two, 40% of the interventions still did not reach a consensus and needed to be discussed in round three, suggesting that those who did not agree in round one did not change their mind in round two. Following the conclusion of the meeting, the experts involved confirmed that the final document was the true representation of the meeting.

Weaknesses of the developed framework include having no items on education that are specifically tailored to motivate towards self-management. It is important to include formalised patient education programmes that will guide the health behaviour changes so that PWSCI may be able to relieve the pain.98 There were no items about telerehabilitation, and in light of the coronavirus disease 2019 (COVID-19) pandemic, it may be worthwhile to determine which self-management techniques may be conducted using such technology. Telerehabilitation may be telephone- or internet-based and may be beneficial in not only improving communication with health professionals in the core skills of self-management but also ensuring that prescribed interventions are performed accordingly. Telephone-based counselling can be considered for affected individuals who have to isolate or quarantine for prolonged periods, as this technique has been shown to improve pain management,99 coping skills, and reduce depression in people with disabilities.27 Notwithstanding the aforementioned limitations, the developed guided pain self-management intervention framework has the potential to improve pain management after SCI.


Although the evidence does highlight the involvement of some health professions over others in SCI care, it is recommended that future Delphi studies employ specific sampling strategies to ensure that all professions are adequately recruited to prevent loss of representativeness as the rounds progress. It is also recommended that further research be conducted to test the clinical suitability of the interventions included in this framework.


This study created a list of interventions that were informed by PWSCI and based on the opinions of health professional experts that may be used to manage pain for PWSCI. Some of the interventions could be applied by PWSCI at home following appropriate training on how to perform them independently. The final framework consists of 56 interventions that may be appropriate for nociceptive and/or neuropathic pain as selected by a panel of health professionals, and span across the different domains of the biopsychosocial model. Most of the experts agreed that interventions are only as effective when administered correctly, and thus proper education on how to perform the interventions adequately and safely is imperative. It must be noticed that all the interventions that were agreed on would not necessarily be appropriate for all PWSCI, and the type, area and severity of the pain would need to be thoroughly assessed. Furthermore, the effectiveness of these interventions needs to be established before the implementation of this framework into clinical practice. This is the first framework of self-management interventions developed for the SCI population to the knowledge of the authors. Pain after SCI has been reported to be difficult to manage and the authors envision this framework to play a vital role in assisting health professionals to know the array of interventions appropriate to guide PWSCI towards pain relief. Having a sense of control over one’s care is positively associated with emotional well-being and an improved ability to deal with stress. An individual’s belief in their capabilities can positively impact mood, subsequently reducing the experience of their pain.


The authors would like to thank all the experts who participated in this study.

Competing interests

The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

Authors’ contributions

M.K.M. conceptualised and designed the study, performed the data collection and analysis, drafted the manuscript and created all the figures and tables included in this manuscript. E.K. and D.J.M. edited the manuscript in fulfilment of the doctoral research of M.K.M.

Funding information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.


The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.


  1. Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34(6):535–546. https://doi.org/10.1179/204577211X13207446293695
  2. Kalpakjian CZ, Scelza WM, Forchheimer MB, et al. Preliminary reliability and validity of a Spinal Cord Injury Secondary Conditions Scale. J Spinal Cord Med. 2007;30(2):131–139. https://doi.org/10.1080/10790268.2007.11753924
  3. Post M, Noreau L. Quality of life after spinal cord injury. J Neurol Phys Ther. 2005;29(3):139–146. https://doi.org/10.1097/01.npt.0000282246.08288.67
  4. Jaglal SB, Munce SE, Guilcher SJ, et al. Health system factors associated with rehospitalizations after traumatic spinal cord injury: A population-based study. Spinal Cord. 2009;47(8):604–609. https://doi.org/10.1038/sc.2009.9
  5. Mashola MK, Olorunju SAS, Mothabeng J. Factors related to hospital readmissions in people with spinal cord injury in South Africa. S Afr Med J. 2019;109(2):107–111. https://doi.org/10.7196/SAMJ.2019.v109i2.13344
  6. Van Gorp S, Kessels AG, Joosten EA, et al. Pain prevalence and its determinants after spinal cord injury: A systematic review. Eur J Pain. 2015;19(1):5–14. https://doi.org/10.1002/ejp.522
  7. IASP. Terminology [homepage on the Internet]. [updated 2021; cited 2022 Jan 24]. Available from: https://www.iasp-pain.org/resources/terminology/
  8. Ataoğlu E, Tiftik T, Kara M, et al. Effects of chronic pain on quality of life and depression in patients with spinal cord injury. Spinal Cord. 2013;51(1):23–26. https://doi.org/10.1038/sc.2012.51
  9. Mashola MK, Mothabeng DJ. Associations between health behaviour, secondary health conditions and quality of life in people with spinal cord injury. Afr J Disabil. 2019;8:463. https://doi.org/10.4102/ajod.v8i0.463
  10. Ditor DS, Latimer AE, Ginis KA, et al. Maintenance of exercise participation in individuals with spinal cord injury: Effects on quality of life, stress and pain. Spinal Cord. 2003;41(8):446–450. https://doi.org/10.1038/sj.sc.3101487
  11. Cardenas DD, Felix ER. Pain after spinal cord injury: A review of classification, treatment approaches, and treatment assessment. PM&R. 2009;1(12):1077–1090. https://doi.org/10.1016/j.pmrj.2009.07.002
  12. Tran J, Dorstyn DS, Burke AL. Psychosocial aspects of spinal cord injury pain: A meta-analysis. Spinal Cord. 2016;54(9):640–648. https://doi.org/10.1038/sc.2016.66
  13. Stanos S, Brodsky M, Argoff C, et al. Rethinking chronic pain in a primary care setting. Postgrad Med. 2016;128(5):502–515. https://doi.org/10.1080/00325481.2016.1188319
  14. Pilusa S, Myezwa H, Potterton J. Exploring prevention and management of secondary health conditions in people with spinal cord injury in South Africa. Int J Ther Rehabil. 2021;28(12):1–10. https://doi.org/10.12968/ijtr.2021.0005
  15. Mulroy SJ, Thompson L, Kemp B, et al. Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: A randomized controlled trial. Phys Ther. 2011;91(3):305–324. https://doi.org/10.2522/ptj.20100182
  16. Van Straaten MG, Cloud BA, Zhao KD, et al. Maintaining shoulder health after spinal cord injury: A guide to understanding treatments for shoulder pain. Arch Phys Med Rehabil. 2017;98(5):1061–1063. https://doi.org/10.1016/j.apmr.2016.10.005
  17. Widerström-Noga E, Biering-Sørensen F, Bryce TN, et al. The international spinal cord injury pain extended data set (Version 1.0). Spinal Cord. 2016;54(11):1036–1046. https://doi.org/10.1038/sc.2016.51
  18. Guy S, Mehta S, Leff L, et al. Anticonvulsant medication use for the management of pain following spinal cord injury: Systematic review and effectiveness analysis. Spinal Cord. 2014;52(2):89–96. https://doi.org/10.1038/sc.2013.146
  19. Cratsenberg KA, Deitrick CE, Harrington TK, et al. Effectiveness of exercise programs for management of shoulder pain in manual wheelchair users with spinal cord injury. J Neurol Phys Ther. 2015;39(4):197–203. https://doi.org/10.1097/NPT.0000000000000103
  20. Darnall BD, Carr DB, Schatman ME. Pain psychology and the biopsychosocial model of pain treatment: Ethical imperatives and social responsibility. Pain Med. 2017;18(8):1413–1415. https://doi.org/10.1093/pm/pnw166
  21. Schaffler J, Leung K, Tremblay S, et al. The effectiveness of self-management interventions for individuals with low health literacy and/or low income: A descriptive systematic review. J Gen Intern Med. 2018;33(4):510–523. https://doi.org/10.1007/s11606-017-4265-x
  22. Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: Implications for health education practice (part I). Health Promot Pract. 2005;6(1):37–43. https://doi.org/10.1177/1524839904266790
  23. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469–2475. https://doi.org/10.1001/jama.288.19.2469
  24. Kroll T, Neri MT, Ho PS. Secondary conditions in spinal cord injury: Results from a prospective survey. Disabil Rehabil. 2007;29(15):1229–1237. https://doi.org/10.1080/09638280600950603
  25. Barlow J, Wright C, Sheasby J, et al. Self-management approaches for people with chronic conditions: A review. Patient Educ Couns. 2002;48(2):177–187. https://doi.org/10.1016/s0738-3991(02)00032-0
  26. Gordon K, Rice H, Allcock N, et al. Barriers to self-management of chronic pain in primary care: A qualitative focus group study. Br J Gen Pract. 2017;67(656):e209–e217. https://doi.org/10.3399/bjgp17X688825
  27. Cadel L, DeLuca C, Hitzig SL, et al. Self-management of pain and depression in adults with spinal cord injury: A scoping review. J Spinal Cord Med. 2020;43(3):280–297. https://doi.org/10.1080/10790268.2018.1523776
  28. Grady PA, Gough LL. Self-management: A comprehensive approach to management of chronic conditions. Am J Public Health. 2014;104(8):e25–e31. https://doi.org/10.2105/AJPH.2014.302041
  29. Lorig KR, Holman H. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med. 2003;26(1):1–7. https://doi.org/10.1207/S15324796ABM2601_01
  30. Liddy C, Blazkho V, Mill K. Challenges of self-management when living with multiple chronic conditions: Systematic review of the qualitative literature. Can Fam Physician. 2014;60(12):1123–1133. https://www.cfp.ca/content/60/12/1123.short
  31. Devan H, Hale L, Hempel D, et al. What works and does not work in a self-management intervention for people with chronic pain? Qualitative systematic review and meta-synthesis. Phys Ther. 2018;98(5):381–397. https://doi.org/10.1093/ptj/pzy029
  32. Mann EG, Lefort S, Vandenkerkhof EG. Self-management interventions for chronic pain. Pain Manag. 2013;3(3):211–222. https://doi.org/10.2217/pmt.13.9
  33. Munce SE, Webster F, Fehlings MG, et al. Perceived facilitators and barriers to self-management in individuals with traumatic spinal cord injury: A qualitative descriptive study. BMC Neurol. 2014;14:48. https://doi.org/10.1186/1471-2377-14-48
  34. Eubank BH, Mohtadi NG, Lafave MR, et al. Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology. BMC Med Res Methodol. 2016;16:56. https://doi.org/10.1186/s12874-016-0165-8
  35. Landeta J. Current validity of the Delphi method in social sciences. Technol Forecast Soc Change. 2006;73(5):467–482. https://doi.org/10.1016/j.techfore.2005.09.002
  36. McPherson S, Reese C, Wendler MC. Methodology update: Delphi studies. Nurs Res. 2018;67(5):404–410. https://doi.org/10.1097/NNR.0000000000000297
  37. Meshkat B, Cowman S, Gethin G, et al. Using an e-Delphi technique in achieving consensus across disciplines for developing best practice in day surgery in Ireland. J Hosp Adm. 2014;3(4):1–8. https://doi.org/10.5430/jha.v3n4p1
  38. Mashola MK, Korkie E, Mothabeng DJ. The presence of pain in community-dwelling South African manual wheelchair users with spinal cord injury. S Afr J Physiother. 2022;78(1):1600. https://doi.org/10.4102/sajp.v78i1.1600
  39. Mashola MK, Korkie E, Mothabeng DJ. Pain and its impact on functioning and disability in manual wheelchair users with spinal cord injury: a protocol for a mixed-methods study. BMJ Open. 2021;11(1):e044152. https://doi.org/10.1136/bmjopen-2020-044152
  40. Jünger S, Payne SA, Brine J, et al. Guidance on conducting and eEporting sElphi studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliat Med. 2017;31(8):684–706. https://doi.org/10.1177/0269216317690685
  41. Clibbens N, Walters S, Baird W. Delphi research: Issues raised by a pilot study. Nurse Res. 2012;19(2):37–44. https://doi.org/10.7748/cnp.v1.i7.pg21
  42. Erlingsson C, Brysiewicz P. A hands-on guide to doing content analysis. Afr J Emerg Med. 2017;7(3):93–99. https://doi.org/10.1016/j.afjem.2017.08.001
  43. Brady SR. Utilizing and adapting the delphi method for use in qualitative research. Int J Qual Methods. 2015;14(5):1–6. https://doi.org/10.1177/1609406915621381
  44. Navein J, Coupland R, Dunn R. The tourniquet controversy. J Trauma. 2003;54(5):S219–S20. https://doi.org/10.1097/01.TA.0000047202.16935.E9
  45. Rothemeyer SJ, Enslin JN. Surgical management of pain. S Afr Med J. 2016;106(9):858–860. https://doi.org/10.7196/samj.2016.v106i9.11366
  46. Pickering G, Estève V, Loriot MA, et al. Acetaminophen reinforces descending inhibitory pain pathways. Clin Pharmacol Ther. 2008;84(1):47–51. https://doi.org/10.1038/sj.clpt.6100403
  47. Teasell RW, Mehta S, Aubut JA, et al. A systematic review of pharmacologic treatments of pain after spinal cord injury. Arch Phys Med Rehabil. 2010;91(5):816–831. https://doi.org/10.1016/j.apmr.2010.01.022
  48. Davari M, Amani B, Amani B, et al. Pregabalin and gabapentin in neuropathic pain management after spinal cord injury: A systematic review and meta-analysis. Korean J Pain. 2020;33(1):3–12. https://doi.org/10.3344/kjp.2020.33.1.3
  49. Baltenberger EP, Buterbaugh WM, Martin BS, et al. Review of antidepressants in the treatment of neuropathic pain. Ment Health Clin. 2015;5(3):123–133. https://doi.org/10.9740/mhc.2015.05.123
  50. Wright SL. Limited utility for benzodiazepines in chronic pain management: A narrative review. Adv Ther. 2020;37(6):2604–2619. https://doi.org/10.1007/s12325-020-01354-6
  51. Jackson KC. Pharmacotherapy for neuropathic pain. Pain Pract. 2006;6(1):27–33. https://doi.org/10.1111/j.1533-2500.2006.00055.x
  52. Stanos SP. Topical agents for the management of musculoskeletal pain. J Pain Symptom Manage. 2007;33(3):342–355. https://doi.org/10.1016/j.jpainsymman.2006.11.005
  53. Stillman M, Capron M, Mallow M, et al. Utilization of medicinal cannabis for pain by individuals with spinal cord injury. Spinal Cord Ser Cases. 2019;5:66. https://doi.org/10.1038/s41394-019-0208-6
  54. Nabata KJ, Tse EK, Nightingale TE, et al. The therapeutic potential and usage patterns of cannabinoids in people with spinal cord injuries: A systematic review. Curr Neuropharmacol. 2021;19(3):402–432. https://doi.org/10.2174/1570159X18666200420085712
  55. Jensen MP, Barber J, Romano JM, et al. Effects of self-hypnosis training and EMG biofeedback relaxation training on chronic pain in persons with spinal-cord injury. Int J Clin Exp Hypn. 2009;57(3):239–268. https://doi.org/10.1080/00207140902881007
  56. Netchanok S, Wendy M, Marie C, et al. The effectiveness of Swedish massage and traditional Thai massage in treating chronic low back pain: A review of the literature. Complement Ther Clin Pract. 2012;18(4):227–234. https://doi.org/10.1016/j.ctcp.2012.07.001
  57. Heo I, Shin BC, Kim YD, et al. Acupuncture for spinal cord injury and its complications: A systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2013;2013:364216. https://doi.org/10.1155/2013/364216
  58. Lundwall A, Ryman A, Bjarnegård Sellius A, et al. Pain requires processing – How the experience of pain is influenced by basic body awareness therapy in patients with long-term pain. J Bodyw Mov Ther. 2019;23(4):701–707. https://doi.org/10.1016/j.jbmt.2019.02.006
  59. Ali MN, Sethi K, Noohu MM. Comparison of two mobilization techniques in management of chronic non-specific low back pain. J Bodyw Mov Ther. 2019;23(4):918–923. https://doi.org/10.1016/j.jbmt.2019.02.020
  60. Hing W, Bigelow R, Bremner T. Mulligan’s mobilization with movement: A systematic review. J Man Manip Ther. 2009;17(2):39E–66E. https://doi.org/10.1179/jmt.2009.17.2.39E
  61. Geneen LJ, Moore RA, Clarke C, et al. Physical activity and exercise for chronic pain in adults: An overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4(4):CD011279. https://doi.org/10.1002/14651858.CD011279.pub3
  62. Costello M, Puentedura ELJ, Cleland J, et al. The immediate effects of soft tissue mobilization versus therapeutic ultrasound for patients with neck and arm pain with evidence of neural mechanosensitivity: A randomized clinical trial. J Man Manip Ther. 2016;24(3):128–140. https://doi.org/10.1179/2042618614Y.0000000083
  63. De Alencar Caldas VV, Maciel DG, Cerqueira MS, et al. Effect of pain education, cryotherapy, and transcutaneous electrical nerve stimulation on the pain, functional capacity, and quality of life in patients with nonspecific chronic low back pain: A single-blind randomized controlled trial. Am J Phys Med Rehabil. 2021;100(3):243–249. https://doi.org/10.1097/PHM.0000000000001552
  64. Fuentes JP, Armijo Olivo S, Magee DJ, et al. Effectiveness of interferential current therapy in the management of musculoskeletal pain: A systematic review and meta-analysis. Phys Ther. 2010; 90(9):1219–1238. https://doi.org/10.2522/ptj.20090335
  65. Anju M, Maiya AG, Hande M. Low level laser therapy for the patients with painful diabetic peripheral neuropathy – A systematic review. Diabetes Metab Syndr. 2019;13(4):2667–2670. https://doi.org/10.1016/j.dsx.2019.07.035
  66. Celik EC, Erhan B, Gunduz B, et al. The effect of low-frequency TENS in the treatment of neuropathic pain in patients with spinal cord injury. Spinal Cord. 2013;51(4):334–337. https://doi.org/10.1038/sc.2012.159
  67. Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry needling for upper-quarter myofascial pain: A systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(9):620–634. https://doi.org/10.2519/jospt.2013.4668
  68. Patel K, Sutherland H, Henshaw J, et al. Effects of neurofeedback in the management of chronic pain: A systematic review and meta-analysis of clinical trials. Eur J Pain. 2020;24(8):1440–1457. https://doi.org/10.1002/ejp.1612
  69. Andersen TE, Ellegaard H, Schiøttz-Christensen B, et al. Somatic Experiencing® for patients with low back pain and comorbid posttraumatic stress symptoms – A randomised controlled trial. Eur J Psychotraumatol. 2020;11(1):1797306. https://doi.org/10.1080/20008198.2020.1797306
  70. Muzik O, Reilly KT, Diwadkar VA. “Brain over body” – A study on the willful regulation of autonomic function during cold exposure. Neuroimage. 2018;172:632–641. https://doi.org/10.1016/j.neuroimage.2018.01.067
  71. Su Y, Lim EC. Does evidence support the use of neural tissue management to reduce pain and disability in nerve-related chronic musculoskeletal pain?: A systematic review with meta-analysis. Clin J Pain. 2016;32(11):991–1004. https://doi.org/10.1097/AJP.0000000000000340
  72. Burns AS, Delparte JJ, Ballantyne EC, et al. Evaluation of an interdisciplinary program for chronic pain after spinal cord injury. PM&R. 2013;5(10):832–838. https://doi.org/10.1016/j.pmrj.2013.05.004
  73. Alahmari KA, Rengaramanujam K, Reddy RS, et al. The immediate and short-term effects of dynamic taping on pain, endurance, disability, mobility and kinesiophobia in individuals with chronic non-specific low back pain: A randomized controlled trial. PLoS One. 2020;15(9):e0239505. https://doi.org/10.1371/journal.pone.0239505
  74. Lynning M, Svane C, Westergaard K, et al. Tension and trauma releasing exercises for people with multiple sclerosis – An exploratory pilot study. J Tradit Complement Med. 2021;11(5):383–389. https://doi.org/10.1016/j.jtcme.2021.02.003
  75. Namdari S, Horneff JG, Baldwin K, et al. Muscle releases to improve passive motion and relieve pain in patients with spastic hemiplegia and elbow flexion contractures. J Shoulder Elbow Surg. 2012;21(10):1357–1362. https://doi.org/10.1016/j.jse.2011.09.029
  76. Dang D, Dearholt SL. Johns Hopkins nursing evidence-based practice: Model & guidelines. 3rd ed. Indianapolis: Sigma Theta Tau International; 2018.
  77. Gargon E, Crew R, Burnside G, et al. Higher number of items associated with significantly lower response rates in COS Delphi surveys. J Clin Epidemiol. 2019;108:110–120. https://doi.org/10.1016/j.jclinepi.2018.12.010
  78. Veugelers R, Gaakeer MI, Patka P, et al. Improving design choices in Delphi studies in medicine: The case of an exemplary physician multi-round panel study with 100% response. BMC Med Res Methodol. 2020;20(1):156. https://doi.org/10.1186/s12874-020-01029-4
  79. Zale EL, Maisto SA, Ditre JW. Interrelations between pain and alcohol: An integrative review. Clin Psychol Rev. 2015;37:57–71. https://doi.org/10.1016/j.cpr.2015.02.005
  80. Parkerson HA, Zvolensky MJ, Asmundson GJ. Understanding the relationship between smoking and pain. Expert Rev Neurother. 2013;13(12):1407–1414. https://doi.org/10.1586/14737175.2013.859524
  81. Richardson EJ, Richards JS, Stewart CC, et al. Effects of nicotine on spinal cord injury pain: A randomized, double-blind, placebo controlled crossover trial. Top Spinal Cord Inj Rehabil. 2012;18(2):101–105. https://doi.org/10.1310/sci1802-101
  82. Todd KR, Lawrason SVC, Shaw RB, et al. Physical activity interventions, chronic pain, and subjective well-being among persons with spinal cord injury: A systematic scoping review. Spinal Cord. 2021;59(2):93–104. https://doi.org/10.1038/s41393-020-00550-z
  83. Ginis KA, Latimer AE, McKechnie K, et al. Using exercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. Rehabil Psychol. 2003;48(3):157. https://doi.org/10.1037/0090-5550.48.3.157
  84. Tawashy AE, Eng JJ, Lin KH, et al. Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: A correlational study. Spinal Cord. 2009;47(4):301–306. https://doi.org/10.1038/sc.2008.120
  85. Davari M, Amani B, Amani B, et al. Pregabalin and gabapentin in neuropathic pain management after spinal cord injury: A systematic review and meta-analysis. Korean J Pain. 2020;33(1):3–12. https://doi.org/10.3344/kjp.2020.33.1.3
  86. Shiao R, Lee-Kubli CA. Neuropathic pain after spinal cord injury: Challenges and research perspectives. Neurotherapeutics. 2018;15(3):635–653. https://doi.org/10.1007/s13311-018-0633-4
  87. Kaufmann CP, Tremp R, Hersberger KE, Lampert ML. Inappropriate prescribing: A systematic overview of published assessment tools. Eur J Clin Pharmacol. 2014;70(1):1–11. https://doi.org/10.1007/s00228-013-1575-8
  88. Curtin D, Gallagher PF, O’Mahony D. Explicit criteria as clinical tools to minimize inappropriate medication use and its consequences. Ther Adv Drug Saf. 2019;10:1–10. https://doi.org/10.1177/2042098619829431
  89. Clark JM, Cao Y, Krause JS. Risk of pain medication misuse after spinal cord injury: The role of substance use, personality, and depression. J Pain. 2017;18(2):166–177. https://doi.org/10.1016/j.jpain.2016.10.011
  90. Kam PC, Kavanagh R, Yoong FF. The arterial tourniquet: Pathophysiological consequences and anaesthetic implications. Anaesthesia. 2001;56(8):821. [published correction appears in Anaesthesia]. https://doi.org/10.1046/j.1365-2044.2001.01982.x
  91. Evans RW, Ganda J, Van Schalkwyk L, Fabricius DL, Cornelissen M. Blood flow restriction training in South Africa – A panel discussion. S Afr J Sports Med. 2022;34(1):v34i1a14796. https://doi.org/10.17159/2078-516X/2022/v34i1a14796
  92. Bourke JA, Catherwood VJ, Nunnerley JL, et al. Using cannabis for pain management after spinal cord injury: A qualitative study. Spinal Cord Ser Cases. 2019;5:82. https://doi.org/10.1038/s41394-019-0227-3
  93. Stillman M, Capron M, Mallow M, et al. Utilization of medicinal cannabis for pain by individuals with spinal cord injury. Spinal Cord Ser Cases. 2019;5:66. https://doi.org/10.1038/s41394-019-0208-6
  94. Cuijpers P, De Graaf I, Bohlmeijer E. Adapting and disseminating effective public health interventions in another country: Towards a systematic approach. Eur J Public Health. 2005;15(2):166–169. https://doi.org/10.1093/eurpub/cki124
  95. Danilov A, Danilov A, Barulin A, et al. Interdisciplinary approach to chronic pain management. Postgrad Med. 2020;132(suppl. 3):5–9. https://doi.org/10.1080/00325481.2020.1757305
  96. Gatchel RJ, McGeary DD, McGeary CA, et al. Interdisciplinary chronic pain management: Past, present, and future. Am Psychol. 2014;69(2):119–130. https://doi.org/10.1037/a0035514
  97. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008–1015. https://doi.org/10.1046/j.1365-2648.2000.t01-1-01567
  98. Bourbeau J, Nault D, Dang-Tan T. Self-management and behaviour modification in COPD. Patient Educ Couns. 2004;52(3):271–277. https://doi.org/10.1016/S0738-3991(03)00102-2
  99. Dorstyn D, Mathias J, Denson L. Applications of telecounselling in spinal cord injury rehabilitation: A systematic review with effect sizes. Clin Rehabil. 2013;27(12):1072–1083. https://doi.org/10.1177/0269215513488001

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