Related Outcome Tools

Pain

The reported prevalence of chronic pain after spinal cord injury (SCI) is 48 - 94%, with nearly one third rating their pain as severe [1].  Chronic pain is defined as pain persisting for 6 months or more, and having the potential to disrupt physical functioning beyond the parameters imposed by the SCI [2].  Chronic pain is one of the most challenging medical problems associated with SCI [3], and is often perceived as difficult to deal with by the person experiencing it [4], as well as by the health care providers managing it [2].

In general, there are two broad categories of pain: neuropathic and nociceptive pain [5]. 

Nociceptive pain is the result of the normal processing of stimuli that damage or disturb normal tissues.  Nociceptive pain typically occurs above the level of the spinal cord lesion, has an identifiable cause, and may result from musculoskeletal problems such as fractures, rotator cuff-tears, or from visceral (abdominal) problems.

Neuropathic pain is more complex and results from the abnormal processing of sensory input due to damage to the nervous system [6].  Although neuropathic pain can be identified by site (region of sensory disturbance) and by features (sharp, shooting, electric, burning, stabbing), it is difficult to identify a specific stimulus or cause, and persons with SCI may find it difficult to describe the quality of neuropathic pain [6].  Typically, neuropathic pain is present at or below the level of the spinal cord lesion, and is constantly present but fluctuates in intensity depending on the individual’s emotional state or level of fatigue [7]. 

It should be noted that a third sub-type of pain, visceral pain, is also a problem for persons with SCI but is one that has been the least researched [8].  Visceral pain that originates from deep visceral structures and is often localized to the abdomen and characterized as being ‘dull’ or ‘cramping’ [9].  It is a clinical entity with multiple etiologies, of which many remain unknown [8], but probably have both central and peripheral components [10]. 

The presence of pain and difficulties with its management may impede a person’s initial SCI rehabilitation and subsequently impede community re-integration [5, 11, 12].  Chronic pain in people with SCI affects sleeping patterns [5], vocational status [5], sexuality [13], leisure time activities [14], activities of daily living [15], and quality of life (QoL) over and above the consequences of their injury [5].  As well, chronic pain after SCI has been found to be a contributing factor in suicide [16].  Although SCI-related chronic pain has been an under-researched and somewhat ignored topic until recently [17, 18], there are several outcome measures available to researchers and clinicians interested in evaluating the impact of chronic pain on QoL and participation. 

The study of SCI-related pain presents a number of challenges.  Unlike the majority of other secondary health conditions, SCI-related chronic pain not only impacts on QoL and participation, but the expression of pain has been shown to be influenced by these constructs as well.  For instance, social environment factors, such as social support, and affective factors, have been found to influence pain severity and interference in persons with SCI-related pain [19, 20].  Hence, it is important to apply a biopsychosocial perspective to conceptualize the development and maintenance of chronic pain disorders  [21, 22].  Contemporary biopsychosocial models acknowledge a role for biological factors in pain, but also argue that psychosocial variables can, and do, influence pain and functioning in all persons, regardless of the source of pain or the presence of psychopathology [21]. 

Chronic pain after SCI remains a common and potentially devastating secondary health condition that negatively impacts on quality of life.


References

1. Siddall PJ, Loeser JD. Pain Following Spinal Cord Injury. Spinal Cord 2001;39:63-73.

2. Ehde DM, Jensen MP, Engel JM, Turner JA, Hoffman AJ, Cardenas DD. Chronic pain secondary to disability: A review. Clin J Pain 2003;19:3-17.

3. Siddall PJ, McClelland JM, Rutkowski SB, Cousins MJ. A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury. Pain 2003;103:249-57.

4. Widerström-Noga EG, Felipe-Cuervo E, Broton JG, Duncan RC, Yezierski RP. Perceived difficulty in dealing with consequences of spinal cord injury. Arch Phys Med Rehabil 1999;80:580-6.

5. Teasell RW, Mehta S, Aubut J, Foulon BL, Wolfe DL, Hsieh JTC, Townson AF, Short C (2010). Pain Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 3.0.

6. Jadad A, O'Brien MA, Wingerchuk D, Angle P, Biagi H, Denkers M et al. Management of Chronic Central Neuropathic Pain Following Traumatic Spinal Cord Injury. Evid Rep Technol Assess (Summ). 2001 Sep;(45):1-5.

7. Scadding J. Neuropathic pain. Adv Clin Neurosci Rehabil 2003;3:8-14.

8. Kogos Jr SC, Richards JS, Banos JH, Ness TJ, Charlifue SW, Whiteneck GG, Lammertse DP. Visceral pain and life quality in persons with spinal cord injury: A brief report. J Spinal Cord Med 2005;28:333-7.

9. Demirel G, Yllmaz H, Gencosmanglu B, Kesiktas N. Pain following spinal cord injury. Spinal Cord 1998;36:25-8.

10. Ness TJ. Chronic abdominal, groin, and perineal pain of visceral origin. In: Wilson P, Haddox D, Jensen T, editors. Textbook of clinical pain management. London, England: Arnold; 2003. 567-86.

11. Tonack M, Hitzig SL, Craven BC, Campbell K, Boschen K, McGillivray CF. Predicting Life Satisfaction after Spinal Cord Injury in a Canadian Sample. Spinal Cord 2008;46: 380-5.

12. Donnelly C, Eng JJ. Pain following spinal cord injury: The impact on community reintegration. Spinal Cord 2005;43:278-82.

13. Westgren N, Hulting C, Levi R, Seiger A, Westgren M. Sexuality in women with traumatic spinal cord injury. Acta Obst Gynecol Scand 1997;76:977-83.

14. Ravenscroft A, Ahmed YS, Burnside IG. Chronic pain after SCI. A patient survey. Spinal Cord 2000;38:611-4.

15. Widerström-Noga EG, Felipe-Cuervo E, Yezierski RP. Chronic pain after spinal injury: Interference with sleep and daily activities. Arch Phys Med Rehabil 2001;82:1571-7.

16. Kewman DG, Tate DG. Suicide in SCI: A psychological autopsy. Rehabil Psychol 1998;43:143-51.

17. Beric A. Spinal cord injury pain. Euro J Pain 2003;7:335-8.

18. Siddall PJ, Taylor DA, Cousins MJ. Classification of pain following spinal cord injury. Pain 1997;35:69-75.

19. Giardino ND, Jensen MP, Turner JA, Ehde DM, Cardenas DD. Social environment moderates the association between catastrophizing and pain among persons with a spinal cord injury. Pain 2003;106:19-25.

20. Widerström-Noga EG, Felix Roy E, Cruz-Almeida Y, Turk DC. Psychosocial subgroups in persons with spinal cord injuries and chronic pain. Arch Phys Med Rehabil 2007;88:1628-35.

21. Jensen MP, Ehde DM, Hoffman AJ, Patterson DR, Czerniecki JM, Robinson LR. Cognitions, coping and social environment predict adjustment to phantom limb pain. Pain 2002;95:133-42.

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