Living and Coping with Chronic Pain
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.

Read more: General Introduction

I don’t expect I’ll ever live without pain, but I need to find ways to live a happy life.

As an avid outdoor athlete, Ida had skied, hiked and been a passionate swimmer for most of her life. Though trained as a tailor, at the time of the accident she was employed as cashier at a swimming center. At the age of 54 she had a major ski accident, that left her with a severe polytraumathat included a list of complex injuries:

Read more: Ida's story

Assessment

Ida’s assessment, as in every Rehab Cycle, included four critical aspects: 1) Identification of patient needs and problems from the patient perspective; 2) Identification of problems within clinical examinations, tests and investigations (the health professional perspective); 3) Determination of long-term, program, and cycle goals; and 4) Identification of intervention targets for the defined cycle goals.

Ida’s body structures and functions impairment centered primarily on pain that was constant and focused on the lower back, but extended down to her feet. To assess the intensity of pain, the Visual Analog Scale (VAS)12 was applied. On the VAS scale, Ida’s rated her pain as 8 out of 10. The type of pain was qualified by the health professionals as neuropathic due to its constant and circular characteristics and quality”.

Box 2 | Measuring Pain 13

Reliable and valid measurement systems are needed to determine the effectiveness of interventions against pain. In order to assess pain in SCI patients, there are several major factors that need to be considered, including:

  • Pain quality – the Leeds Assessment of Neuropathic Signs and Symptoms defines and assesses pain qualities such as prickling, feelings of electric shocks, etc. However, there are currently no measures that distinguish neuropathic and non-neuropathic pain.
  • Pain intensity – probably the most common metric, there are a number of frequently used scales that include the Visual Analogue Scale, the Numerical Rating Scale, and the Verbal Rating Scale. These scales have demonstrated consistent psychometric value across various pain populations. The Numerical Scale utilizes a 0-10 rating, with 7-10 indicating severe pain.
  • Pain location(s) – this can complicate assessments when multiple sites are involved. One approach is to assess pain in general, though Jensen et al. note that this “oversimplifies the assessment and can interfere with determining the true effects of pain treatment” with the authors recommending assessing basic information on at least three sites. Pain is often located using human form diagrams or checklists.
  • Affective qualities of pain that include bothersomeness, fear, anger, etc. These can be assessed using the pain intensity scales mentioned above, or with more specific multiple item measures of pain affect such as the McGill Pain Questionnaire.
Read more: Assessment

Assignment and Intervention

The health professionals described, among other problems, reduced functional mobility of joints, muscle endurance, and increased muscle spasms and therefore all members of Ida’s rehabilitation team were involved in the broad range of interdisciplinary interventions that focused on her two cycle goals. These included her physician, nurse, physical, occupational and sports therapists, as well as her psychologist. Pharmacological interventions were still included and should be adapted to the situation.

As the result of a discussion between the medical doctor and the psychologist, medical anti-depressant therapy was prescribed. While specific drugs were able to mitigate some pain, it was clear that these alone were insufficient to improve her overall participation. Hence, in addition to the pharmacological therapy, a majority of interventions were non-drug based. In order to improve pain management, many interventions centered on improving Ina’s ability to cope with stress. Therefore Ida’s psychologist undertook extensive counseling on pain, coping strategies and carrying out a daily routine.

Read more: Assignment and Intervention

Ida’s rehabilitation program lasted eleven instead of six weeks that were planned during which time she made significant progress and demonstrated improvements overall for both Cycle Goals. Her coping strategies for handling stress were greatly improved, while her mobility abilities made only slight improvement. Importantly, Ida’s VAS score indicated significantly lower perceived pain, with a reduction from 8 to 3 out of 10.

Ida noted that arts therapy including painting and playing music (particularly singing bowls) led her to relax and helped reduce pain. Intervention target improvements were achieved for sleep, drive and emotional functioning.

Read more: Evaluation

Pain - either neuropathic or nociceptive – is highly prevalent in spinal cord injury cases during and/or following rehabilitation, and may even occur or recur years following the time of injury. Pain can greatly compromise quality of life, lead to decreased body functioning, reduce an individual’s capacity to perform activities and overall result in low or reduced participation. Oftentimes, a first line approach to therapy is based upon pharmaceuticals such as analgesics and anti-inflammatory agents.

However, this therapeutic path does not always result in quality-of-life gains. In Ida’s case, the drug-based approach that had been utilized when she was hospitalized three times for pain management had not been effective, failing to reduce her pain (in one instance even increasing her pain) or improve mobility and quality of life. Although she maintained independence in daily living, her constant pain led to reductions in both her range of activities and her ability to participate.
This interdisciplinary rehabilitation approach that included a range of non-pharmacological interventions helped her make strides towards greater pain management, as well as decreases in her pain overall. Here, the primary cycle goal focused on stress reduction and the development of longer term coping strategies.

Read more: Discussion