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Pain Management

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Pain Following SCI Executive Summary
Mehta S, Teasell RW, Loh E, Short C, Wolfe DL, Benton B, Blackport D, Hsieh JTC (2019). Pain Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, Sproule S, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 7.0: p 1-101.


Executive Summary

Pain is a common concern among persons with spinal cord injury. Incidence of pain following SCI can range anywhere from 48 to 92% (Britell & Mariano 1991; Cohen et al. 1988; Mariano 1992; Modirian et al. 2010; Rose et al. 1988Pain often starts immediately after SCI and can continue to increase over time among 47% of individuals; while it decreases in only 7% Turner et al. (2001). ). It is estimated that 30-40% of patients with SCI experience severe disabling pain (Burke & Woodward 1976). Pain is often reported as the most important factor for decreased quality of life. Most studies of chronic SCI pain have focused on the medical causes and clinical manifestations of pain while much less is understood about how psychosocial factors impact SCI pain (Summers et al. 1991). Pain itself was found to be associated with greater emotional distress than the SCI itself. Hence treatment of post-SCI pain should involve these multidimensional aspects.

How is it classified?

Recently, an international group of clinicians and researchers developed a consensus for an SCI pain classification, International Spinal Cord Injury Pain Classification (ISCIP Classification). The ISCIP classification incorporates common pain pathology after SCI even those not necessarily related to SCI itself (Bryce et al. 2012). The system classifies pain at three tiers. Tier 1 includes pain types such as nociceptive, neuropathic, other pain, or unknown pain. Tier 2 provides a subtype of each type, nociceptive pain consists of musculosketal, visceral, and other nociceptive pain types. Neuropathic pain consists of at level, below level, and other neuropathic pain. The last tier defines the primary source of the pain or its related pathology.

What are the management options for pain post SCI?

Currently, anticonvulsants such as gabapentin and pregabalin are considered first line treatment for neuropathic pain post SCI. Other pharmacological approaches to manage pain post SCI pain include tricyclic antidepressants (e.g. amitriptyline), anesthetics (eg. lidocaine), antispastics (e.g. baclofen), opioids, and cannabinoids. There is evidence for the use of several non-pharmacological approaches to pain post SCI including massage, osteopathy, acupuncture, transcranial direct current stimulation, transcranial electrical stimulation, transcutaneous electrical nerve stimulation, transmagnetic stimulation, neuromuscular electrical stimulation, functional electrical stimulation, diet, and physical activity. Behavioural management of SCI related pain include approaches such as visual illusion, biofeedback, hypnotic suggestion, mindfulness, and cognitive behaviour therapy. Surgical approaches are considered last line of management strategies used to treat intractable pain. These include spinal cord stimulation, dorsal longitudinal t-myelotomy, and dorsal rhizotomy.

Gaps in the Evidence

Though the pain experience is multidimensional, there is surprisingly a lack of evidence for multimodal approaches to pain management. Studies evaluating the combination of non-pharmacological, behavioural, and pharmacological approaches should be evaluated. There is a lack of evidence on which approaches work best for each type of pain. Studies targeting treatments to specific types of pain are warranted. Lastly, there is a lack of evidence on the effectiveness of several treatments over long term follow-ups, with most studies limiting follow-ups to months.