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Spinal Cord Injury Update

 

Spring 2009: Volume 18, Number 1

 

Treating SCI pain: What the research says

By Jeanne Hoffman, PhD, UW rehabilitation psychologist

Contents

Treatment for spinal cord injury (SCI) pain continues to be a focus of research. Studies over the last two years have examined the effectiveness of medications, brain stimulation, exercise, acupuncture and psychological approaches such as hypnosis and biofeedback. Most research has focused on neuropathic pain.

Understanding research studies

There are many different kinds of research studies, and the way they are designed often determines how good the results are. Randomized controlled trials (RCTs) are considered the best or “gold standard” of study designs. In RCTs, participants with the same type of medical problem are randomly (by chance) assigned to one of two or more different treatments, one of which might be a placebo (inactive substance that has no treatment value). The groups are compared at the end of the study to see whether one treatment was better than another.
However, RCTs are often difficult to do and require a large number of participants. For this reason, initial studies, including studies examining just a few people who undergo a treatment (called case studies) are more common. Much of the evidence in pain management after SCI so far comes from initial studies.

Medications for pain

A recent review of research studies (Basstrup & Finnerup, 2008) found that there have only been 10 RCTs of medication treatments for neuropathic pain. Most found no difference between the study medication compared to a placebo. Those drugs that did show some reduction in pain were gabapentin and pregabalin (originally developed for treating seizures and found to help with pain) and amitriptyline (originally developed as an anti-depressant but found more effective for pain). The review also suggested that opioids (narcotics such as codeine and morphine) can relieve neuropathic pain. Another study (Rintala, 2007) found that amitriptyline may be more effective than gabapentin in treating SCI pain. Botox has also been studied (Naumann et al., 2008) and was found to lessen pain from detrusor sphincter dyssynergia (bladder spasms) after SCI.

Brain stimulation

In a case study, 12 patients with central pain received repetitive transcranial magnetic stimulation (rTMS), in which electrodes are placed on the scalp to stimulate the motor cortex (Defrin et al., 2007). Results of this study suggest that rTMS may be useful if given over time. A study using cranial electrotherapy with ear clip electrodes produced pain reduction in those with SCI (Tan et al., 2006). Canavero and Bonicalzi (2007) in Italy have suggested that producing a small stereotactic lesion deep in the brain may provide relief of central pain. However, another study done in Germany on deep brain stimulation found no benefit for individuals with SCI (Rasche et al., 2006).

Acupuncture

A case study of acupuncture on 17 people with shoulder pain found that pain decreased with both acupuncture and sham (fake) acupuncture (Dyson-Hudson et al., 2007).

Exercise

A case study using virtual walking found some evidence for improved neuropathic pain located at the level of injury (Moseley, 2007). Actual exercise, using circuit resistance training, was found to improve strength and endurance and reduce shoulder pain (Nash et al., 2007). In another study, an eight-week home exercise program reduced pain and improved function in persons with SCI and shoulder pain. (Nawoczenski et al., 2006).

Psychological factors

Having good social support has been found to lower pain after SCI (Widerstrom-Noga et al., 2007). A review by Jensen and colleagues (2007) reports that neuropathic pain can reduce quality of life and suggests that biopsychological (vs. only medical interventions) approaches may be useful. A case study on 12 individuals with SCI using healing touch and progressive relaxation was found to reduce pain and increase a feeling of well-being (Wardell et al., 2006).

What treatment might work for you?

Since everyone’s pain is different and no single treatment works for everyone, it is important to work with your physician to manage your pain. Siddall and Middleton (2006) suggested an algorithm (steps to follow) for physicians to use when treating patients with pain after SCI. This involves properly diagnosing the type and potential causes of pain. Treatment is then given based on the problem and on the known literature of pain management techniques.

References
1. Baastrup C, Finnerup NB. Pharmacological management of neuropathic pain following spinal cord injury. CNS Drugs. 2008;22(6):455-75.
2, Canavero S, Bonicalzi V. Central pain syndrome: elucidation of genesis and treatment. Expert Rev Neurother. 2007 Nov;7(11):1485-97.
3. Defrin R, Grunhaus L, Zamir D, Zeilig G. The effect of a series of repetitive transcranial magnetic stimulations of the motor cortex on central pain after spinal cord injury. Arch Phys Med Rehabil. 2007 Dec;88(12):1574-80.
4. Dyson-Hudson TA, Kadar P, LaFountaine M, Emmons R, Kirshblum SC, Tulsky D, Komaroff E. Acupuncture for chronic shoulder pain in persons with spinal cord injury: a small-scale clinical trial. Arch Phys Med Rehabil. 2007 Oct;88(10):1276-83.
5. Jensen MP, Chodroff MJ, Dworkin RH. The impact of neuropathic pain on health-related quality of life: review and implications. Neurology. 2007 Apr 10;68(15):1178-82.
6. Moseley GL. Using visual illusion to reduce at-level neuropathic pain in paraplegia. Pain. 2007 Aug;130(3):294-8.
7. Nash MS, van de Ven I, van Elk N, Johnson BM. Effects of circuit resistance training on fitness attributes and upper-extremity pain in middle-aged men with paraplegia. Arch Phys Med Rehabil. 2007 Jan;88(1):70-5.
8. Naumann M, So Y, Argoff CE, Childers MK, Dykstra DD, Gronseth GS, Jabbari B, Kaufmann HC, Schurch B, Silberstein SD, Simpson DM. Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2008 May 6;70(19):1707-14.
9. Nawoczenski DA, Ritter-Soronen JM, Wilson CM, Howe BA, Ludewig PM. Clinical trial of exercise for shoulder pain in chronic spinal injury. Phys Ther. 2006 Dec;86(12):1604-18.
10. Rasche D, Rinaldi PC, Young RF, Tronnier VM. Deep brain stimulation for the treatment of various chronic pain syndromes. Neurosurg Focus. 2006 Dec 15;21(6):E8.
11. Rintala DH, Holmes SA, Courtade D, Fiess RN, Tastard LV, Loubser PG. Comparison of the effectiveness of amitriptyline and gabapentin on chronic neuropathic pain in persons with spinal cord injury. Arch Phys Med Rehabil. 2007 Dec;88(12):1547-60.
12. Siddall PJ, Middleton JW. A proposed algorithm for the management of pain following spinal cord injury. Spinal Cord. 2006 Feb;44(2):67-77.
13. Tan G, Rintala DH, Thornby JI, Yang J, Wade W, Vasilev C. Using cranial electrotherapy stimulation to treat pain associated with spinal cord injury. J Rehabil Res Dev. 2006 Jul-Aug;43(4):461-74.
14. Wardell DW, Rintala DH, Duan Z, Tan G. A pilot study of healing touch and progressive relaxation for chronic neuropathic pain in persons with spinal cord injury. J Holist Nurs. 2006 Dec;24(4):231-40
15. Widerström-Noga EG, Felix ER, Cruz-Almeida Y, Turk DC. Psychosocial subgroups in persons with spinal cord injuries and chronic pain. Arch Phys Med Rehabil. 2007 Dec;88(12):1628-35.

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