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Managing chronic pain has been reported as one of the most important factors impacting quality of life for people after SCI, with the incidence of pain following SCI ranging from 48 – 92 % (1).  

National Data collected by the Rick Hansen Spinal Cord Injury Registry (RHSCIR) from April 2020 – September 2021 indicated 86 % of people with traumatic SCI reported pain during Acute care, and 70 % of people with traumatic SCI reported pain during Rehabilitation Care.  

Pain is complex, and can be a very individual experience impacted by overall physical health and psychosocial factors, making it difficult to find effective treatment solutions. Pain interferes with sleep, return to work, quality of life and participation in regular activities (2). Pain often occurs immediately after SCI and can continue as chronic pain, often increasing as a result of other complications such as a pressure injury, urinary tract infection, anxiety or other psychosocial factors (3). 

The different types of pain that a person can experience after injury, as well as the individual’s response to medications and treatments, leads to the complexity of pain management. In 2012, Bryce et al worked with an international group of clinicians and researchers to establish a comprehensive, well defined, classification of pain after SCI. The goal of this work was for clinicians and researchers to develop a consensus-based classification in order to develop and provide effective targeted treatments. (4)

Spinal Cord Injury Clinical Practice Guidelines

Prior to 2016 there were no formal standards of care or recommendations for providing treatment for pain for people with SCI. A working group was established with the objective to develop Canadian Spinal Cord Injury (CSCI) clinical practice guidelines (CPG) for the management of neuropathic pain in people with SCI. This working group was comprised of an international panel of pain experts from the areas of Physiatry, Psychology, Pain Medicine, Allied Health & Nursing, Research and Psychology. This group developed the CanPain SCI Clinical Practice Guidelines, which were first  published in 2016 and then updated in 2021. They are specific to adults with SCI within  the rehabilitation and community settings, and encompass screening, diagnosis, treatment, as well as outlining the model of care in which they should be delivered.  

The 2021 guidelines recommend a Model of Care for managing neuropathic pain in people with SCI that is patient-centered and incorporates a coordinated and interprofessional Team Approach. The model of care identifies a biopsychosocial  framework that is evidence-based and delivered in a timely manner. These guidelines state that all patients with SCI must be screened for pain, with a focus on underlying conditions and psychosocial factors that can aggravate neuropathic pain and may contribute to pain-related distress and disability.

Pain Screen The International Spinal Cord Injury Pain Basic Data Set (v 2.0) is the recommended Pain Screen. See link below.

General Treatment Principles highlight the importance of establishing an interdisciplinary team that provides patient education, group discussion, and behavioural self-management programs such as visual illusion, biofeedback, stretching, mindfulness, and cognitive behaviour therapy.

Treatment recommendations specify the first-line and second-line of pharmacology treatments for neuropathic pain, as well as outline secondary options, which include Botulinum toxin A and Cannabinoids. Specific dosage was not identified, but rather, healthcare professionals are encouraged to prescribe these treatments based on patient preference, accessibility, and clinician experience.

The other treatment modalities listed included: 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. A summary of the guidelines can be found here.

During the Alberta SCI Annual Education Day 2022, David J Allison, PhD, provided education on the Management of Neuropathic Pain after SCI and reviewed the CanPain SCI Clinical Practice Guidelines.

Cognitive Behaviour Therapy

Cognitive Behaviour Therapy (CBT) has been recognized as an important psychological intervention for individuals to help self-manage their wellbeing by understanding how their thoughts and ideas can influence actions and beliefs. (5) When addressing neuropathic pain and how care should be delivered, it is recognized that completely alleviating pain is not always a realistic goal. CBT is being used successfully  to support people with SCI to learn techniques and strategies to manage negative thoughts and modify beliefs to regulate their remaining pain. Literature has shown that multidisciplinary cognitive behavioural programs such as CBT can have lasting improvements on pain intensity, pain-related disability, and anxiety for people with chronic neuropathic spinal cord injury pain (6,7).

Recognizing there are many barriers that prevent face-to face CBT sessions, Swati Mehta and her team examined the effectiveness of guided Internet delivered Cognitive Behavior Therapy (ICBT) as an alternative approach for mental health service delivery after SCI. Participants were provided with a guided 8-week ICBT program, with the results of the study indicating good completion rates. Participants reported an improvement in quality of life, as well as better management of depression and anxiety at completion of the program and at 3 month follow up. Results of this study suggest that ICBT may be an effective and cost-effect form of psychosocial service delivery for those with SCI and concerns with mental health.

Dan McLean sustained a T4 AIS A SCI in April 2019 as a result of a hunting incident. After completing his rehabilitation at G.F. Strong in Vancouver he returned to his home in Kamloops, BC, ready to take on the challenges of life in a wheelchair. Unfortunately, one of the biggest and most difficult challenges for Dan was the constant and unrelenting neuropathic pain that began shortly after his return home.

Dan explains that this pain has impacted every aspect his life,  including relationships, returning to work, and leisure activities. Dan describes his  pain as feeling like barbed wire being wrapped around his chest, numbness in his  buttocks, and burning down his legs. He explains that he has constant pain, which  intensifies with stress or anxiety, and is aggravated by cold weather, bending  forward in his wheelchair, AND all the fun stuff of “over-eating, drinking beer  (hangovers), smoking cigars, sex and viagra…” Dan explains that he has followed  the recommendations of his medical team, working through the medication  guidelines, and trying different modalities such as massage and breathing exercises, finding that some strategies will provide some relief, even if only  temporarily. Dan is still focused on finding a more long-term pain management strategy, with the next steps including a S1 nerve block treatment, followed by percutaneous spinal cord stimulation. Overall, he is optimistic that this will provide some lasting management of his pain.  

Dan wants to emphasize to the medical community that every SCI is different and  every person responds differently to the drugs and types of treatments. Dan has  found some relief in “mindfulness” and being able to distract himself by playing video games. He encourages clinicians and those affected by SCI to work closely together as a team, and be open to exploring all options and strategies to find what works the best for managing neuropathic pain, that also fits within the lifestyle goals.

Dan has shared his story in the documentary Re-Inventing The Wheel. This film shows a unique community of wheelchair-users guide newly injured Dan McLean and his wife Colleen through Dan’s first year of life as a paraplegic.

Note: To watch this film, you will need to join Vimeo On Demand (enter your email  and create a password) and “purchase” the video. The film is free with promo code: Wheels 

Opportunity for New Sites to Join International Research Projects External to Praxis

Please note, this is not a comprehensive list. Please see here for a complete list of all current SCI trials.

1. International Spinal Cord Injury Society (ISCoS) Covid-19 Dataset

Objective: To gain an in-depth understanding of the characteristics, clinical presentation, disease course (frequency and duration of symptoms) and outcomes of COVID-19 in the SCI population, as well as to understand the impact of the pandemic on the lives of people with SCI.
Study Population:  Individuals with a traumatic or non-traumatic SCI, of any neurological level and complete or incomplete, age ≥ 18 years and diagnosed with COVID-19 (based on a confirmed case definition).
Intervention: This is an observational cohort study involving two surveys (clinician-reported and self-reported) that will be implemented in countries using a standardized methodology.
Contact: Mohit Arora, contact at mohit.arora@sydney.edu.au or James Middleton, contact at james.middleton@sydney.edu.au

2. A Combinatorial Intervention in Acute Spinal Cord Injury (SCI)

Objective: To determine whether the medical drink Souvenaid® enhances neurological outcome (primary outcome is lower limb performance) following acute traumatic SCI.
Study Population: Individuals with acute traumatic SCI (C1-T12 AIS A-D), age 18-70 years, recruited <15 days post injury).
Intervention: Randomized controlled design; standard best care (including rehabilitation) with daily orally administered Souvenaid® for 12 months versus standard best care (including rehabilitation).
Contact: Euan McCaughey, contact at e.mccaughey@neura.edu.au

3. Abdominal Functional Electrical Stimulation (FES) to Reduce Respiratory Complications in Spinal Cord Injury (SCI)

Objective: To determine whether abdominal functional electrical stimulation (FES) reduces the proportion of patients suffering a respiratory complication in acute tetraplegia.
Study Population: Individuals with acute tetraplegia (age >18 years, recruited 5-10 days post injury).
Intervention:  Randomized controlled design; abdominal FES (50% of participants) and placebo abdominal FES (50% of participants) will be applied to the abdominal muscles for 45 minutes per day, 5 days per week, for 5 weeks.
Contact: Euan McCaughey, contact at e.mccaughey@neura.edu.au

People in Pain Network has established a free Virtual Peer Pain Support Group with monthly meetings that offer a balance between education and support for people with chronic pain to learn strategies to manage pain and improve quality of life.

The Christopher Reeve Foundation has created easy to understand resources on pain management that can be shared with anyone impacted by SCI.  

The videos define musculoskeletal pain, neuropathic pain and visceral pain, and explains how changes to the body after SCI and the mechanisms behind the injury can lead to chronic pain after SCI. 

They have also created a Pain-Management booklet that can be printed or shared electronically.  

Pain BC is a registered health charity that has been leading efforts to improve the lives of people in pain through empowerment, care, education and innovation. Pain BC has created a podcast to share information on chronic pain from pain experts and people living with pain. They discuss options for pain management, helpful tools, and current research being conducted. Learn more at painbc.ca.

Spinal Cord Injury Research Evidence (SCIRE) has been reviewing and providing the best evidence in SCI care since 2006. SCIRE has created a resource for professionals that provides detailed, evidence-based information on pharmacology treatment and non-pharmacological approaches to pain management.  

The Pain Management Network based out of New South Wales, Australia has developed resources for persons with SCI, their family and caregivers that provides education on pain and how to develop a SCI pain management plan. Experts in the field of Pain Management and persons with lived experience explore the importance of creating a Health Plan to be used in combination with medication and non-pharmacology strategies to improve function and quality of life.

We hope you enjoyed this edition of SCI Line. Your feedback is important to us, and we welcome suggestions for future content. Please connect with our team at clinical@praxisinstitute.org

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