Clinically Based Research: Advances in the Evaluation and Treatment of Pain in Persons with Spinal Cord Injury and Disease: An Overview of Recent Research Findings
Erin Dehon, BS; and Samuel T. Gontkovsky, PsyD
Pain is a significant complication for a large percentage of individuals with spinal cord injury and disorders (SCI/D). In its acute form, pain often serves a protective function, acting as a signal to prevent further damage and consequently to expedite healing. In some instances, pain persists far beyond the period for which healing of the injury may be expected. This chronic pain serves no meaningful purpose and can actually suppress the body’s immune system leading to further medical complications. Chronic pain has also been shown to be associated with negative emotional symptomatology and decreased quality of life among persons with SCI. Its accurate identification and treatment, therefore, is of critical importance.
Evaluation of pain in persons with disorders of the spinal cord is in many ways challenging. Individuals with SCI/D may experience nociceptive pain, neuropathic pain, or both. Whereas nociceptive pain originates from the noxious stimulation of a pain receptor, neuropathic pain is generated as a result of damage to the sensory pathways. It can be especially difficult for healthcare professionals to determine the specific basis for a person’s complaints of pain following onset of a spinal disorder. Furthermore, the identification of pain type among individuals with SCI/D has been hampered by a lack of reliable and valid assessment methods. These difficulties in the appropriate identification of pain have yielded corresponding challenges in pain treatment post-SCI/D, since the pharmacological interventions for the alleviation of nociceptive pain vs. neuropathic pain are essentially mutually exclusive.
Hope remains, however, as findings of new research published during the past year suggest that meaningful advances are being made in both the evaluation and the treatment of pain among persons with SCI/D. Summaries of three excellent empirical studies are presented below.
EVALUATION OF PAIN FOLLOWING SCI
Reliability of the Bryce/Ragnarsson spinal cord injury pain taxonomy
Bryce, T. N., Dijkers, M. P. J. M., Ragnarsson, K.T., Stein, A. B., & Chen, B.
Estimates of the number of persons with SCI who develop chronic pain are quite divergent. Since there presently exists no widely accepted tool to categorize pain, clinicians rely on a number of different classification schemes in evaluating this problem post-SCI. Differing methods for evaluating pain have not only resulted in the aforementioned variation in prevalence estimates, but have also led to decreased knowledge of pain dynamics following SCI. This limitation has further hampered advances in the development of appropriate treatment strategies.
This study examined the interrater reliability of the Bryce/Ragnarsson spinal cord injury pain taxonomy (BR-SCI-PT). Thirty-nine physicians with expertise in SCI were asked to evaluate different types of pain based on 135 vignettes describing a person with SCI who was experiencing pain, and each physician reported their confidence in the correctness of their classification. Their answers were compared with those of the investigators. Ninety-three percent of the pain levels (above/at/below neurological level of injury) were categorized correctly. Ninety percent of the pain categories were described correctly as being either nociceptive or neuropathic. Eighty-three percent of pain descriptions were categorized correctly to one of the fifteen pain types listed on the BR-SCI-PT. Participants also indicated a high degree of confidence in the correctness of their classifications.
These results suggest that physicians who possess only some degree of instruction in classifying pain can use the BR-SCI-PT with confidence. Nevertheless, this comprehensive taxonomy of pains should be evaluated further in order to increase its reliability. Researchers may improve the response reliability by providing specific inclusion and exclusion criteria for each pain subtype. Increased reliability and validity of the BR-SCI-PT likely will translate to its increased use among clinicians and researchers, with the ultimate goal being to improve the treatment of pain post-SCI.
Journal of Spinal Cord Medicine, 29, 118–132. 2006
TREATMENT OF POST-SCI PAIN
Treatment for chronic pain in persons with spinal cord injury: A survey study.
Cardenas, D. D., & Jensen, M. P.
Individuals with SCI commonly suffer from chronic pain and experience substantial problems in managing this pain. Much is still unknown about the pathophysiologic changes that occur after SCI that result in chronic pain. This investigation examined the efficacy of various types of pain treatments evaluated by individuals with SCI, evaluating both the degree and duration of pain relief provided by each treatment.
Participants were 117 adults with SCI who reported experiencing chronic pain post-injury. The mean age of the sample was 48.8 ± 11.7 years, and the amount time since injury varied from 3.2–57.4 (mean 17.3 ± 10.4) years. Participants were asked in a survey questionnaire to indicate the type of pain treatment they were receiving, to provide a rating evaluating the effectiveness of each treatment, and to specify the duration of time for which the pain relief typically lasts.
Results indicate that more than 96% of participants with pain reported trying at least one of the pain medications listed in the survey. Medications reported by participants to be used most often were nonsteroidal anti-inflammatory drugs and acetaminophen, and more than half of the individuals who said that they had tried these medications reported their continued use. Most medications used by participants were generally described as providing only short-term alleviation of discomfort, usually only several hours. Tricyclic antidepressants were reported to provide a longer duration of pain relief but at only modest levels. Although opioids were said to produce the greatest relief of pain, participants were not likely to continue taking them. Even though anticonvulsants such as gabapentin are increasingly being used to treat neuropathic pain, participants reported only moderate pain relief with their use, and few indicated taking these medications beyond the initial trial period.
Seventy-three percent of participants reported seeking pain relief using at least one of seven alternative treatments listed in the survey. The most frequently tried were massage, marijuana, and acupuncture; the most relief was provided by massage and marijuana. Pain relief was reported to last for days for about 25% of those who received massage or acupuncture. Relief of severe pain also was reported from strengthening exercises and physical therapy. Overall, results revealed that most medications do not adequately alleviate pain for individuals with SCI, and that non-pharmacological interventions, including alternative therapies, should be considered in combination with drugs.
Journal of Spinal Cord Medicine, 29, 109–117. 2006
PAIN IN MULTIPLE SCLEROSIS
Correlates of pain interference in multiple sclerosis
Osborne, T. L., Turner, A. P., Williams, R. M., Bowen, J. D., Hatzakis, M., Rodriguez, A., & Haselkorn, J. K.
Multiple sclerosis (MS) is a chronic disease involving demyelination of the axons in the central nervous system. Although not historically recognized as a problem among individuals with MS, pain has recently been reported to be experienced by 40–80% of this clinical population, with the degree, duration, and type of pain varying dramatically. Investigations have also revealed that pain in MS is associated with restricted daily activities, decreased social functioning, and poorer mental and physical health. The objective of this study was to examine pain interference and its relationship with various indices of health and psychosocial functioning.
Participants were 451 veterans with MS who completed various measures assessing pain interference, fatigue, general health, perceived social support, and depression symptom severity. Participants also provided information regarding basic demographics, MS type, and gait disability. The results indicated a moderate level of overall pain interference among participants, with the greatest interference related to participation in recreational activities. Those with progressive MS reported higher levels of pain interference than did those with relapsing/remitting MS. Correlational analysis indicated that fatigue, general health, perceived social support, and depression symptom severity were all significantly associated with pain interference.
Since there is currently no cure for MS, it is important for healthcare professionals to be knowledgeable about the pain experienced by persons with this disease and its potential negative effects on other domains of functioning in order to better provide effective treatment and minimize functional impairment.
Rehabilitation Psychology, 51, 166–174. 2006
CONCLUSION
The high prevalence estimates of pain among persons with injury or disease of the spinal cord and the associated detrimental consequences of this pain indicate a need for ongoing research to explore the etiological mechanisms of pain and to develop more effective strategies for both identification and treatment. The research summarized in this report suggests that the BR-SCI-PT shows substantial promise as an effective instrument for assessing pain in individuals with SCI. It also seems that the current trend of treatment for pain is not necessarily the most effective, as individuals with SCI report only minimal pain relief with most medications.
Clearly, there is a need to more systematically examine non-pharmacological forms of therapy, including psychosocial interventions, for pain following SCI/D. Nevertheless, recent studies, such as these, show promise for the future.
Erin Dehon, BS, is a doctoral student in the Department of Psychology, Jackson State University, Jackson, MS.
Samuel T. Gontkovsky, PsyD, is an associate professor in the Department of Psychology, Jackson State University, and a scientist at the Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, MS.