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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:
-
Relaxation training to reduce the amount of physiologic arousal
that exacerbates pain.
-
Self-hypnosis and positive imagery are helpful for controlling
temporary episodes of pain.
-
Practical
behavioral changes such as increasing sleep, reducing smoking,
or improving self-care methods.
-
Cognitive
restructuring to help people reinterpret the sensations they
experience, refocus on other activities, or distract themselves
from pain can be very helpful.
-
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.
-
Self-monitoring
to identify pain-exacerbating activities.
-
Increasing
social activities to reduce boredom and the amount of thought
on pain.
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