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Because of legal restrictions, MOMSCIS cannot give specific medical advice. The following information is not a substitute for the personal care or advice of your physician. Please discuss any concerns with your physician regarding your medical care. Physicians in the Physical Medicine & Rehabilitation Department at the University of Missouri-Columbia are available to evaluate patient records, and can set up a clinic visit for a medical evaluation. The PM&R Department does extensive treatment of individuals with spinal cord injuries using a wide variety of physical therapies and state-of-the-art medications. Individuals with spinal cord injuries can be examined and treated on an outpatient or inpatient basis. For more information about the PM&R services available or to schedule a clinic visit, telephone the clinic at (573) 884-0033.
Pain management
What Causes It? How Can It Be Treated?
Pain – one of the most common problems after spinal cord injury. Research indicates that 18 percent to 63 percent of people with spinal cord injury report “severe or disabling” chronic pain. When complaints of “mild to moderate” pain are included, the prevalence rate jumps to 94 percent.
What causes this pain, and how can it be treated? The MOMSCIS Report (a predecessor to today’s Spinal Series newsletter) will address these questions in a series of articles on SCI-related pain. Dr. Steve Gnatz, (former) chairman of MU’s Department of Physical Medicine and Rehabilitation, says there are many possible causes of post-SCI pain.
“Fractures and soft-tissue injuries related to the initial trauma, as well as damage to the spinal nerve roots, are common causes of pain,” Dr. Gnatz says. “Once rehabilitation begins, we also see pain associated with overuse of muscles, tendons, and joints. For example, starting physical therapy and/or beginning to use a wheelchair can place greater than usual demands on the arms, shoulders, chest, and back.”
Other causes of SCI-related pain are more mysterious. How is it possible for a person to experience pain in a paralyzed body part? Several theories exist, but the exact mechanism is unknown.
One theory suggests that the complex chemical and electrical pathways of pain are modified by the trauma of SCI such that sensations normally perceived as nonpainful would be misinterpreted by the brain as pain. Another theory proposes that after SCI, a malfunction can develop in the system designed to dampen pain transmissions. The net result is experienced as an amplification of pain sensation.
Whatever the underlying mechanisms may be, chronic pain interferes with a person’s ability to work, participate in social activities, and enjoy life. In the next issue of the MOMSCIS Report, Dr. Michael Acuff will discuss treatment options available to alleviate SCI-related pain.
Pain Relief Please
By Michael Acuff, M.D., SCI Specialist
and Laura Meyer, former MOMSCIS Data Coordinator
Pain can be a major factor in the life of an individual with a spinal cord injury. Each person's experience of pain is as individual as his or her life-style and level of injury. According to Dr. Michael Acuff, a physiatrist at Rusk Rehabilitation Center, it is necessary to look at the "big picture" before identifying a treatment method. This means considering such factors as an individual's diet, exercise program, skin health, bladder and bowel management program, and activity level.
Once a thorough patient history and physical exam have been completed, the next step is to consider treatment options. In some cases, the source of pain is readily identifiable and easily treated. "For example," Acuff says, "a person with pelvic or lower abdominal pain may have a bladder stone that needs to be removed or a person with back pain may need to have rods and plates removed."
In situations where surgery is unnecessary, there are a number of other options. Medication is a common method of pain management. There are two major types of pain medication: non-narcotic and narcotic. Nonnarcotics include antidepressants, antiinflammatories, anticonvulsants and antipsychotics.
According to Dr. Acuff, "non-narcotics can be quite effective in decreasing level of pain perception as well as allowing sleep and relaxation." Side effects such as drowsiness and bowel or bladder function impairment may be noted with this type of medication. However, most people can expect significant pain reduction through the use of non-narcotics.
Narcotic medications provide pain relief by increasing the concentration of natural painkillers. However, Acuff says, narcotics "do not relieve pain at the source but rather decrease pain perception." Most doctors prefer to use narcotics only as a short-term treatment option because of various side effects and the suppression of the body's natural painkilling abilities.
Another method of pain management is electrical stimulation, which is effective for 30%-40% of individuals with spinal cord injury-related pain. Electrical stimulators may either be placed on the painful region and regulated by adjusting controls or implanted into the spinal canal and on top of the spinal cord. If treatment proves effective, an individual may either consider purchasing a unit for prolonged use or having a catheter surgically implanted.
Dr. Acuff says, "Surgical procedures such as cutting the nerves or destroying the nerve fibers or nerve cells have been done in the past but few hospitals or surgeons perform these types of surgeries for spinal cord pain today."
Other methods of pain control include acupuncture, Chinese medical techniques, and regulation of diet. Although employed less frequently, they are of some merit and may be successful with the supervision of a trained health care provider.
The ultimate goal of a pain management program is to enable optimum functioning given an individual's injury and life-style. Through the careful application of one or more pain treatment approaches, it is possible to both decrease the pain and to maintain lasting control of it. Individuals suffering from spinal cord injury-related pain should work with their health care providers to develop an effective pain-management plan which allows them to stay active in their treatment.
Treating chronic pain
- Search for cause
- Consider pain to be a symptom of syrinx (or syringomyelia, an abnormal fluid cavity inside the spinal cord)
- Acknowledge the reality of pain
- Monitor efficacy of pain relief methods
- Control spasticity
- Use transcutaneous electrical nerve stimulation if effective
- Initiate stress management/relaxation skills
- Monitor efficacy of pain relief methods
- Educate and involve family and enlist support and cooperation
- Do not always expect to find a specific cause for the pain
- Avoid prolonged use of narcotics
- Be aware of painkiller-induced constipation
- Do not argue with pain complaints or its realness
- Do not reinforce or support pain behaviors
Pain Relief
By Kristofer Hagglund, Ph.D.
Clinical Psychologist & MOMSCIS Principal Investigator
The good news is that there is significant ongoing research in the area of pain among people with spinal cord injury and new treatment methods are being refined and developed frequently.
Chronic pain is a major challenge to individuals with spinal cord injury. Pain often limits the types or amount of activities in which individuals participate. It leads also to problems with family and social relationships, and can lead to depression or anxiety. The health care community does not yet fully understand pain in SCI, but evidence suggests that chronic pain in SCI has been underestimated and not adequately treated.
Pain is best treated by a multidisciplinary approach. As noted in previous columns, pain can be caused or maintained by many “factors” such as anatomical problems, physiological dysfunction, environmental stressors or psychological or social problems. Therefore, treatment may involve a traditional medical approach or it may involve other highly effective treatments.
In the previous issue of The Spinal Column (the immediate predecessor to today’s Spinal Series newsletter), Dr. Acuff described some of the most common medical approaches, including medications, electrical stimulation, therapeutic modalities such as heat or ice, and, less frequently, surgical procedures. In the remainder of this column, I will describe just a few of the many ways in which psychological, social, and environmental factors can influence pain.
A common psychological contributor to pain is the meaning attached to pain. Many individuals have feared that their pain is a symptom of a larger problem such as a tumor or other life-threatening illness. When this happens, the fear and dread from this belief causes increased physiological arousal (fight or flight response) that subsequently makes the pain worse. Conversely, individuals who are able to “reinterpret” their pain often do much better. For example, a person who says “I have learned to cope with spinal cord injury, so I can learn to cope with pain as well” is more likely to learn strategies to control pain and increase his/her ability to engage in desirable activities.
Social effects can also influence pain. One example involves health care professionals. Unfortunately, health care professionals sometimes minimize the impact of pain among people with spinal cord injury by saying or implying “you are lucky to be alive, even though you have pain” or “we can’t find the source of your pain – you will just have to learn to live with it.” Although this is happening less often, it does interfere with the relationships between health care providers and their patients. Also, it leaves consumers without any strategies to control their pain or reduce its negative impact on their lives.
Other social influences that tend to worsen pain include conflict with friends or family members, daily hassles, and negative life events. It is important to learn about pain behavior and its affect on others. Often others are afraid to approach people or even actively avoid people who show that they have pain. Learning to communicate effectively about pain can sometimes be very helpful.
Environmental factors can also affect pain. Examples of these influences that may worsen pain include an ill-fitting wheelchair or cold conditions.
Pain management recognizes the importance of psychological, social, and environmental factors in addition to traditional medical approaches. Pain management should be designed to help people both control pain and increase desired social, recreational, and other activities of daily life. A multidisciplinary team that includes physicians, therapists, psychologists, social workers, and recreation therapists is sometimes needed for effective pain control.
Pain is a complex problem that is not well understood by the health care community. Individuals experiencing pain related to spinal cord injury should contact their health care providers and work on developing an effective pain control plan in which they can participate.
Here are a few psychological and social treatments that are often used to control pain:
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Relaxation training to reduce the amount of physiologic arousal that exacerbates pain.
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Self-hypnosis and positive imagery are helpful for controlling temporary episodes of pain.
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Practical behavioral changes such as increasing sleep, reducing smoking, or improving self-care methods.
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Cognitive restructuring to help people reinterpret the sensations they experience, refocus on other activities, or distract themselves from pain can be very helpful.
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Understanding the link between pain and depression or pain and anxiety is enough to help people control their thoughts and reduce the amount of pain they experience.
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Self-monitoring to identify pain-exacerbating activities.
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Increasing social activities to reduce boredom and the amount of thought on pain.
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