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SCI Forum

 

Managing Chronic Pain after Spinal Cord Injury


Presented on January 14, 2014 at the University of Washington Medical Center, Seattle, WA.

Chronic (or long-standing) pain is a common problem for people living with spinal cord injury, and it is often very difficult to treat. In this forum video, two UW Rehabilitation Medicine clinicians discuss the different types, causes and potential treatment options for chronic pain.

In Part 1, Medical Approaches, Deborah Crane, MD, MPH, assistant professor and rehab physician at Harborview, reviews medications, surgical options, injections, pumps, massage, and other treatments.

In Part 2, Self-Management Techniques, Dawn Ehde, PhD, professor and rehab psychologist, discusses different self-management strategies for decreasing and coping with chronic pain, including relaxation, pacing and hypnosis.

Watch the video below or read the report.

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Report

 

Chronic Pain and SCI: Part 1, Medical Approaches

 

By Deborah Crane, MD, MPH, Assistant Professor of UW Rehabilitation Medicine and SCI physician at Harborview Medical Center.

 

Contents

Pain is very common after spinal cord injury. Statistics vary, but generally about four out of five people with SCI report significant chronic pain. Of those, about one-third report the pain interferes with their quality of life and their daily activities. 

Types of pain in SCI

Pain can be either nociceptive or neuropathic. Nociceptive pain means the nerve endings that are intact are actually being irritated by some sort of noxious or irritating stimulus and you are receiving true pain signals. Musculoskeletal and visceral pain are both nociceptive. Neuropathic pain is caused by abnormal communication between the damaged nerves in your spinal cord and the pain centers of your brain.

Musculoskeletal pain

Musculoskeletal pain is usually a dull or achy pain felt above your level of injury where the muscles are innervated normally or have not been affected by your spinal cord injury. It is usually triggered or worsened by movement. 

Types and causes of musculoskeletal pain

Treatments for musculoskeletal pain

It is important to work with your physical and occupational therapists (PTs and OTs) to make sure you are following good biomechanics so you can keep your joints as healthy as possible. There are several approaches to treating musculoskeletal pain:  

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Visceral pain

This refers to pain in the abdominal area. It is often described as dull, achy, or crampy pain that comes and goes. It can be vague and hard to describe, especially if you don't have normal sensation in that area. Visceral pain is caused by some sort of abdominal problem that needs treatment, such as constipation, kidney stones, ulcers, appendicitis, bladder stones, gallstones, or a gastrointestinal kind of virus.

Neuropathic pain 

In contrast to nociceptive pain, neuropathic pain is caused by abnormal communication between the damaged nerves in your spinal cord and the pain centers of your brain. The pain is often described as pins and needles, burning, throbbing or stabbing. It can be at the level of injury, where your sensation or your strength changes, above the level of injury, or below the level of injury. Usually there is not a specific trigger for the pain, and the pain is often fairly constant. 

Neuropathic pain is complex and usually requires a combination of treatment approaches to manage. The first step is always to see if there is any medical complication causing the pain. Your doctor can help with this. 

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Medications for neuropathic pain

Acetaminophen (Tylenol) is often overlooked because people may not think it’s strong enough, but for many patients it is helpful, especially in combination with other medications. 

Antidepressants. There are two major types commonly used for nerve pain. 

Anticonvulsants. Seizure medicines such as gabapentin and pregabalin (Lyrica) also work well against nerve pain. 

NSAIDs or nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil), naproxen (Aleve), and celecoxib (Celebrex) are not frequently use for nerve pain, but they sometimes can be helpful in combination with other drugs. Side effects are mild and some people may get stomach upset; however, taking too much for too long can damage kidneys.

Opioids (narcotic medications)
Most people with SCI had this type of medication when they were first were injured and still in the hospital. These drugs come in either long-acting (methadone, morphine, oxycodone, and fentanyl, lasting 8-12 hours) or short-acting (morphine, oxycodone, hydrocodone and hydromorphone, lasting 2-4 hours) formulations. Short and long-acting medications are often prescribed together, to combat  the spikes of intense pain that break through the long-acting dose.  

Side effects of opioids (narcotic medications)

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Topical medications

Medications that you rub onto your skin can be helpful for some kinds of pain, but they are only practical for small areas of the body.  
Capsaicin. The active ingredient in these creams comes from chili pepper. Capsaicin tends to work better if you use it multiple times throughout the day.
Lidocaine is a numbing medicine similar to what the dentist gives you in a shot form. Lidoderm patches are stickers with the lidocaine medication impregnated in them. They can be very expensive and are not covered by many insurance companies. 
Diclofenac or voltaren gel is an anti-inflammatory gel.   

Other treatments

Marijuana (cannabis) has been found to be effective in reducing nerve pain and spasticity in some studies of people with SCI and other disabilities. Go to “The Use of Medical Marijuana to Manage Symptom Burden in Spinal Cord Injury” at  http://sci.washington.edu/summit2014/medical_marijuana.asp for a comprehensive discussion about medical marijuana for SCI pain.

Surgery for nerve pain is not common but may be helpful in a few specific cases, such as a pinched nerve in your spine (nerve root compression) or a peripheral nerve injury such as an ulnar nerve injury at the elbow or carpal tunnel syndrome. Likewise, syrinx formation (a cyst in the spinal cord) or nerve root tethering (nerves stuck in scar tissue) may require surgery.

Acupuncture is considered a neurostimulatory technique in which needles are inserted in various points in the skin. While some people say it works well, research has not found it to be effective. It doesn’t really have any negative side effects, however, and may be worth a try. 

Massage therapy.  There is research data that shows people with SCI are using massage as a frequent pain treatment and finding it effective. While some insurers do pay for therapeutic massage, others unfortunately do not.
 
A TENS unit.  TENS stands for transcutaneous electrical nerve stimulation and uses electric current delivered through patches applied to the skin. TENS is often most useful for pain in a specific area, such as SCI pain at your level of injury, radicular or nerve root type pain, or musculoskeletal pain. 

Heat and ice can be helpful for individuals with muscular pain. Do not to apply heat or ice to areas of your body that don’t have normal sensation, however, because you can get burns or frostbite. 

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Chronic Pain and SCI: Part 2, Self-Management Techniques

 

By Dawn Ehde, PhD, Professor of UW Rehabilitation Medicine and rehab psychologist at Harborview Medical Center.

 

Contents

Most pain in SCI is chronic, meaning that it is long-lasting and fairly continuous. You are the one who's dealing with it every day, and you are therefore the expert on it. 

What is self-management? 

Teresa Brady from the Centers for Disease Control defined it this way: “Self-management simply means what people do on a day-to-day basis to feel better and pursue the life they desire.” 

In self-management the important question is not “How or why did I get the pain?” but rather “What can I do to manage my pain so that I can get on with my life?” The main goal of self-management is helping people get back to participating in life and doing the things they want to be doing despite the pain. 

While medical and rehab interventions are certainly important in managing pain, research has shown repeatedly for more than 50 years that pain is much more than just a medical problem. It affects and is affected by all aspects of a person’s life—feelings, relationships, behaviors. It is best understood as a biopsychosocial phenomenon, meaning  physical, emotional and social factors all play a role in the way you experience pain.

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Self-management skills

There are some very concrete practical self-management skills that can help you manage chronic pain. 

Set a goal

One of the most important things in taking back your life when living with pain is to set a goal.

Steps for setting goals. 

  1. State your goal.
  2. Make sure your goal is both manageable and realistic. 
    • On a scale from 1 to 10, how confident are you that you can reach your goal?
    • A rating between 0–6 means that the goal is too hard and needs to be broken down into smaller pieces.
    • A rating of 7 to 10 means it’s a good fit.
  3. List steps that will help you reach your goal
  4. Evaluate results. Did you reach your goal?

Another goal-setting approach is to make a statement specifying what you will do, how often, which days, what barriers you anticipate and how you will deal with them. This ensures that your goal is tangible and doable.

Activation

One of the most important ways to treat both pain and emotional suffering is “activation” or getting active.  Getting active may include:

Activation works best If activities are:

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Relaxation skills. 

We know when the brain is in a more relaxed state the body tends to hurt less.  And relaxation is helpful for coping in general.  There are many different techniques for relaxation.

Progressive muscle relaxation
This method involves systematically tensing and relaxing the muscle groups in your body that you can move, one group at a time. The idea is to give you an awareness of tension in your body and what it feels like to release that tension.

Breathing

Even simpler, you can use your breathing as a form of relaxation. I’ve even done breathing relaxation with people on ventilators before, which involves counting breaths and using this as a path toward relaxation.  This can often be used in conjunction with imagery—thinking about a place that you associate with relaxation and feeling good while you are doing relaxation exercises.

Relaxation Practice is Key

Yoga

Yoga can provide a combination of breathing, relaxation and positive imagery skills. There are many different types; look for one that accommodates people of all abilities and experience levels.

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Hypnosis

Hypnosis for managing pain (called hypnotic analgesia) in SCI is backed by scientific evidence. Several studies here in the University of Washington Department of Rehabilitation Medicine have found that hypnosis is very helpful in reducing pain in about a third of people with spinal cord injury pain.  About another third say it helps some, and a third say it doesn't really help very much at all.

You won’t know if you're going to be someone who benefits from it unless you give it a try.

What is hypnosis?
Hypnosis is a state of focused attention and use of imagery to get you into a very relaxed state. While in that state you listen to positive suggestions (from a therapist or audiotape) for decreasing unpleasant experiences and increasing comfortable experiences.

The process goes something like this:

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Mindfulness

Mindfulness is simply being aware of the present moment and having a nonjudgmental attitude towards your present thoughts and feelings. This method can help people relax and be less bothered by chronic pain.  There are many mindfulness resources and trainings available, including the Mindfulness-Based Stress Reduction Programs at the Center for Mindfulness in Medicine, Health Care, and Society (www.umassmed.edu/cfm).

 

Depression and Pain

Major Depressive Disorder (MDD) is much more common among individuals with chronic pain, including SCI pain. Often pain and depression occur together, and evidence suggests that pain precedes depression more often than the reverse.

It is very important that you know the symptoms of depression: feeling down and blue most of the time; having low energy; not wanting to get out there and do things, or be with others.  Check with your health care provider if you think you might be depressed, because depression can make pain worse, and there are effective treatments for depression.

Other pain treatments

Self-management also includes asking for help from mental health professionals trained in specific behavioral and psychological techniques.

Cognitive‐behavioral therapy (CBT) for pain

Acceptance and Commitment Therapy (ACT)

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Resources

 

Pain Self‐Help Books

Online Self‐Management Programs

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