I know what it’s like to live without pain – and that makes living with it so much worse.

For many persons with a spinal cord injury (SCI) a life of living with and attempting to manage pain is a severe complication that can have a tremendous impact on quality of life and the ability to carry out activities of daily living. In about 34% of persons with SCI, the pain starts immediately after the injury and in about 58% within the first year post-injury1. Estimates for chronic pain vary from 11-96%.2 For those suffering from pain, pain increased over time in 47% and decreased only in 7%.13 Hence, living with pain after SCI is very common.

Pain - A Challenge to Daily Living

Pain exacerbates the problems caused by the physical disability24 and it is the most important contributor to decreased quality of life2 by significantly interfering with performing activities of daily living such as driving, managing the household, engaging in leisure activities such as sports and enjoying a social life. In addition, constant or worsening pain may also result in psychological conditions such as depression and in very severe cases even suicide.5 Coping with pain is not only a challenge for patients but also for health professional. Given the subjective nature of pain, it is often perceived as a symptom that is difficult to adequately assess, in particular since only poor metrics are available for objective assessments. In addition, few evidence exists regarding the effectiveness of comprehensive pain management programs in comparison to pharmacological pain management.

Box 1 | Pain Classification

While over the years there have been many attempts to classify pain, it has been categorized into two forms: nociceptive pain and neuropathic pain.6

Nociceptive pain occurs in the musculoskeletal or visceral systems, generally at or above the level of the lesion. It is pain that is caused by damage to the area surrounding nociceptors – a sensory nerve cell specialized for pain. Such pain can involve bone, joints, muscles (both trauma and spasms), kidney function, bowels, sphincter dysfunction, etc.

Neuropathic pain (also referred to as dysesthetic pain) associated with an impairment of the spinal cord often is described as shooting, burning, cutting, crushing or tingling. This class of pain is often caused by a lesion or dysfunction within the nervous system. It may occur above, below or at the level of injury. Neuropathic pain can be further classified as radicular or central. While radicular pain is spread along the dermatome (sensory distribution) of a nerve due its connection to the spinal column, central pain either be relegated to a specific part of the body or affect the body as a whole (at- and below the level of a SCI)7 Causes may include non-traumatic (e.g. compression, vascular under supply) and traumatic spinal cord injuries.

Management of Pain

Given that neuropathic pain is a multi-faceted bio-psycho-social phenomenon a multi-disciplinary approach to therapy is often most effective.8 Pain management can involve both pharmacological interventions and non-pharmacological approaches. Additionally, a patient centered approach to pain management is important, empowering the person experiencing the pain in managing and directing her own care. To achieve this, a range of rehabilitation interventions is possible.2It should be recognized however that “full recoveries” from chronic pain are not always guaranteed.

Pharmacological pain management is often the first intervention action, including both opioids and non-steroidal anti-inflammatory drugs. In one US study, SCI patients with severe pain or pain in more than one location were more likely to utilize pain medication.9or neuropathic pain associated with SCI, psychotropic drugs such as anti-depressants, anesthetics, anti-spasticity medication and even topical capsaicin (from chili peppers) have all shown degrees of effectiveness.2 It should be noted however that the majority of the medications have not been approved for use in treating pain commonly associated with spinal cord injury; much of the “off-label” use of these medications is based on anecdotal evidence.

Non-pharmacological approaches can also be effective at managing pain, but require additional resources and a broader set of skills by health care providers. These approaches can be broken into two broad groups: physical interventions and psychological interventions. The former include specific exercises such as heat therapy and massage, acupuncture, transcranial magnetic stimulation, sports therapy and hippotherapy.Psychological interventions may include such approaches as hypnosis, cognitive behavioural therapy, as well as arts and music therapy.2

Such interventions may be effective complements to more traditional pharmacological approaches. Studies in SCI patients with neuropathic pain demonstrated the effectiveness of pain interventions that included education, behavioural therapy, relaxation techniques and body awareness training. In these studies, patients’ levels of anxiety and depression in the treatment group decreased compared with baseline values, and showed a tendency towards better quality of sleep and improved sense of coherence 1011.

Given the multiple approaches to pain management comprehensive and inter-disciplinary interventions have to be integrated into rehabilitation programs. This should take place in the post-acute phase with the very first efforts at rehabilitation, and may also include specific rehabilitative programs to mitigate or reduce chronic pain in the later phases.

This case study aims to illustrate multidisciplinary approaches for the comprehensive management of chronic pain in persons with SCI, describing intervention strategies and their application in a specific rehabilitation program of an individual with neuropathic pain following traumatic SCI.