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Spinal cord injury (SCI)-associated pain has a specific classification approach that assists in guiding treatment strategies.
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SCI-related pain seems to be prevalent, but there is considerable variability in the epidemiology of this condition.
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Evaluation of SCI-associated pain relies heavily on history and is supplemented by a neuromusculoskeletal examination and judicious use of laboratory and radiologic testing.
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Relatively few treatments for SCI-associated pain have been extensively studied.
Physical Medicine and Rehabilitation Clinics of North America
Spinal Cord Injury Pain
Section snippets
Key points
Classification
Before 2000, there was no consistent approach to the classification of SCI-related chronic pain. This variability was described by Hicken and colleagues1 during a review in 2002 in which 29 distinct schemes were described with potentially confusing and inconsistent terminology. By 2008, 3 classifications systems emerged as the leading systems based on their utility, comprehensiveness, validity, and reliability. These schemes included the Cardenas classification,2 the taxonomy of the
Epidemiology
Given the classification ambiguity of chronic SCI-related pain described above, attempts at epidemiology can be problematic. Other potential confounders include oversampling because patients may have more than one pain syndrome, adequate pain description, criteria used for chronicity and severity, traumatic versus nontraumatic differentiation, and appropriate inclusion/exclusion criteria. Dijkers and colleagues9 executed a review consisting of 42 articles that described the epidemiology of this
Evaluation
The approach to SCI pain should commence in a manner similar to all chronic pain conditions—history, physical examination, and judicious use of diagnostic testing. Information should be obtained regarding the patient's initial SCI including date, mechanism of injury, associated injuries such as long bone and visceral trauma, description of vertebral column stabilization procedures, and comorbidities of the acute hospitalization and rehabilitation phase of injury. Descriptors should be attained
Nonpharmacologic
A generalized exercise program in the form of global strength training, cardiovascular training, or recreational physical activities has the potential to be beneficial for several SCI-related conditions (eg, spasticity, muscle atrophy, bone health), but its effect on global pain in this population has not been greatly satisfactory. Animal studies have suggested that antinociceptive behaviors can be reduced with weeks of exercise training.19, 20 Extrapolation from these experiments to the human
Summary
SCI pain is clearly a challenging pain syndrome. Each element of this review (classification, epidemiology, evaluation, and management) has demonstrated limitations. Further investigation by clinicians and researchers in both the SCI and pain communities is warranted in an effort to further delineate the nature of this problem and create more effective treatment strategies. Physiatrists are uniquely positioned to participate in this process and should engage in this endeavor whenever possible.
References (70)
- et al.
Classification of chronic pain associated with spinal cord injuries
Arch Phys Med Rehabil
(2002) - et al.
Comparative reliability and validity of chronic pain intensity measures
Pain
(1999) - et al.
Research design considerations for confirmatory chronic pain clinical trials: IMMPACT recommendations
Pain
(2010) - et al.
Symptoms of major depression in people with spinal cord injury: implications for screening
Arch Phys Med Rehabil
(2004) - et al.
Chronic neuropathic pain in spinal cord injury patients: what relevant additional clinical exams should be performed?
Ann Phys Rehabil Med
(2009) - et al.
Extended swimming exercise reduces inflammatory and peripheral neuropathic pain in rodents
J Pain
(2007) - et al.
Is acupuncture effective in treating chronic pain after spinal cord injury?
Arch Phys Med Rehabil
(2001) - et al.
Acupuncture for chronic shoulder pain in persons with spinal cord injury: a small-scale clinical trial
Arch Phys Med Rehabil
(2007) - et al.
Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action
Pain
(1999) - et al.
Comparison of the effectiveness of amitriptyline and gabapentin on chronic neuropathic pain in persons with spinal cord injury
Arch Phys Med Rehabil
(2007)
Efficacy of amitriptyline for relief of pain in spinal cord injury: results of a randomized controlled trial
Pain
Antidepressants and pain
Trends Pharmacol Sci
Duloxetine in patients with central neuropathic pain caused by spinal cord injury or stroke: a randomized, double-blind, placebo-controlled trial
Pain
Tramadol as an analgesic for mild to moderate cancer pain
Pharmacol Rep
Botulinum toxins: mechanisms of action, antinociception and clinical applications
Toxicology
The chronic neuropathic pain of spinal cord injury: which efficiency of neuropathic stimulation?
Ann Phys Rehabil Med
Continuous intrathecal baclofen infusion by a programmable pump in 131 consecutive patients with severe spasticity of spinal origin
Neuromodulation
Intrathecal clonidine and baclofen in the management of spasticity and neuropathic pain following spinal cord injury: a case study
Arch Phys Med Rehabil
Oscillating field stimulation in the treatment of spinal cord injury
PM R
Classification of pain following spinal cord injury: literature review and future directions
Pain following spinal cord injury: clinical features, prevalence and taxonomy
International Association for the Study of Pain
Reliability of the Bryce/Ragnarsson spinal cord injury pain taxonomy
J Spinal Cord Med
International spinal cord injury pain classification: part I. Background and description. March 6–7, 2009
Spinal Cord
International spinal cord injury pain (ISCIP) classification: part 2. Initial validation using vignettes
Spinal Cord
The management of pain in spasticity
Disabil Rehabil
Revisiting physiologic and psychologic triggers that increase spasticity
Am J Phys Med Rehabil
Prevalence of chronic pain after traumatic spinal cord injury: a systematic review
J Rehabil R D
Clinically significant change in pain intensity ratings in persons with spinal cord injury or amputation
Clin J Pain
Pain after spinal cord injury: an evidence-based review for clinical practice and research. Report of the national institute on disability and rehabilitation research spinal cord injury measures meeting
J Spinal Cord Med
Reference for the 2011 revision of the international standards for neurological classification of spinal cord injury
J Spinal Cord Med
Vitamin B12 deficiency in spinal cord injury: a retrospective study
J Spinal Cord Med
Serum 25(OH)D, PTH and correlates of suboptimal 25(OH)D levels in persons with chronic spinal cord injury
Spinal Cord
Three exercise paradigms differentially improve sensory recovery after spinal cord contusion in rats
Brain
Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being
Spinal Cord
Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain
Spinal Cord
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2019, GeneCitation Excerpt :Spinal cord injury (SCI) refers to a chronic wound state that expands and maintains demyelination. SCI is associated with recovery impairment and progressive tissue degeneration (Saulino, 2014). Axonal regeneration at the SCI site rarely occurs, leading to irreversible motor weakness, sensory deficits, and autonomic dysfunction (Ahmed et al., 2011).
Virtual reality for spinal cord injury-associated neuropathic pain: Systematic review
2019, Annals of Physical and Rehabilitation MedicineCitation Excerpt :VR therapy for SCI warrants additional research, but inherent challenges in studying SCI and VR exist. For example, neuropathic pain associated with SCI is heterogeneous in nature and the mechanisms are not fully understood [17,79]. VR protocols vary significantly, which limits inter-study or multi-facility comparisons.
Spinal Cord Injury-Related Neuropathic Pain
2018, Challenging Neuropathic Pain Syndromes: Evaluation and Evidence-Based TreatmentMeta-analysis of stem cell transplantation for reflex hypersensitivity after spinal cord injury
2017, NeuroscienceCitation Excerpt :The prevalence of below-level neuropathic pain is in the order of 20–40% (Norrbrink Budh et al., 2003; Siddall et al., 2003; Werhagen et al., 2004). SCI-NP affects not only patients' physical state, but all aspects of their lives, including work ability, mood, and quality of life; it is also associated with high medical costs (Ferrero et al., 2015; Saulino, 2014). Although many kinds of drugs have been used to treat SCI-NP (e.g., anticonvulsants, antidepressants, and analgesics), even the best treatments have been shown to alleviate only 20–30% of neuropathic pain (Baastrup and Finnerup, 2008).
Aging with Spinal Cord Injury: An Update
2017, Physical Medicine and Rehabilitation Clinics of North AmericaCitation Excerpt :The prevalence of pain after SCI is varied, ranging from 25% to greater than 90% of subjects, depending on the study. There does not seem to be a relationship between age of SCI, completeness of injury, or type of injury in regard to pain.33 It has been shown that the development of neuropathic pain following SCI will most likely continue throughout the patient's life.34
Update on traumatic acute spinal cord injury. Part 2
2017, Medicina Intensiva