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As outlined in our previous issue, 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 %. Chronic pain can interfere with sleep, social activity and work, as well as be correlated with depressive mood and polypharmacy. The different types of pain that a person can experience after SCI - musculoskeletal, neuropathic, visceral - as well as the individual’s response to medications and treatments, leads to the complexity of pain management. In addition, finding effective treatment solutions may be complicated by factors such as the person’s overall health, medical history and psychosocial dynamics  

The Canadian Pain Spinal Cord Injury Clinical Practice Guidelines (CanPain SCI Guidelines), are specific to adults with SCI within the rehabilitation and community settings, and encompass model of care, screening, diagnosis and treatment.

Find a summary of the guidelines here:
Summary of CanPain SCI Guidelines: 2021 

These guidelines recommend the first-line pharmacology treatment options of pregabalin, gabapentin or amitriptyline for managing neuropathic pain after SCI. These guidelines also include a list of non-pharmacology secondary treatments, acknowledging that these options have various levels of evidence or strength of recommendation. With this understating, clinicians are encouraged to make suggestions for these secondary treatments options based on other relevant factors, including patient preference, clinician experience, accessibility, side-effects and tolerance. Cognitive Behavioural Therapy, which includes Mindfulness, is recommended under the secondary treatment options for consideration in the management of chronic pain after SCI.

Multi-disciplinary Cognitive Behavioural Therapy (CBT) has been recognized as a valuable intervention to support people with SCI self-manage their wellbeing by understanding how their thoughts and ideas can influence their actions and beliefs. While CBT interventions challenge core beliefs and negative behaviours, Mindfulness, a component of CBT, focuses on present-moment awareness and acceptance.

Mindfulness refers to reaching a mental state of awareness of the present moment, including sensations, thoughts and consciousness, while also feeling openness and acceptance. Mindfulness can be described as self-regulation of attention, to be aware of our thoughts and feelings, versus mindlessly going through daily activities with self-critical and worrisome thoughts. It is this practice of achieving a mindful state that provides a sense of control over emotional wellbeing, and potentially a sense of control over pain.

Achieving this state takes commitment, and as evidenced by all the self-help books and websites, it requires practice, effort and time. It is not something that you can achieve quickly or easily. Initially, the person may benefit from instructor led exercises, and then progress to auto-guided meditation and eventually feel confident to complete activities independently. These examples of Mindfulness activities are gathered from several different resources which are included in the Reference / Resource section.  

• Body Scan: focusing attention on various areas of the body, noticing detailed sensations.
• Breath Awareness: deep breathing exercises, attention directed to the inhale / exhale experience of breathing.
• Mindful Movement: body movements in time or pace with breaths, focused awareness on small physical movements.
• Meditations: with a focus on oneself as being fluid and ever-changing, emphasizing acceptance, compassion, kindness.
• Meditations: with a focus on pleasant or positive parts of life, appreciation of things that bring pleasure.

Clinical Trial:

• Praxis SCI Accelerate alumni SpineX is conducting a clinical trial to explore the effectiveness of non-invasive neuromodulation on bladder function. Click here to learn more

General Resources:

• To learn more about online mental health services visit the Rehab Psych Lab at https://rehabpsych.sjhc.london.on.ca/ 
• If you are interested in the SCI Wellbeing Program, click here
• Resources from SCIRE Professional click here
• Internet Guided Strategies for Improving Wellbeing after Spinal Cord Injury.  Watch the Interview with Swati Mehta 

Webinars: 

• CBT and Mindfulness: Cognitive Behaviour Therapy: Strategies for Improving Wellbeing after Spinal Cord Injury.  Watch here
• Example session: Using CBT and Mindfulness to support a person struggling with chronic pain. Watch here

Articles: 

• Hearn, J.H., Cross, A. Mindfulness for pain, depression, anxiety, and quality of life in people with spinal cord injury: a systematic review. BMC Neurol 20, 32 (2020) 
• Hearn JH, Finlay KA. Internet-delivered mindfulness for people with depression and chronic pain following spinal cord injury: a randomized, controlled feasibility trial. Spinal Cord. 2018 Aug;56(8):750-761. 
• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research, 36(5), 427–440. 
• Hofmann SG, Gómez AF. Mindfulness-Based Interventions for Anxiety and Depression. Psychiatr Clin North Am. 2017 Dec;40(4):739-749. 
• Bishop SR. Mindfulness: A Proposed Operational Definition. Clinical Psychology: Science and Practice. 2004;11(3):230–241. 
• Burke D, Lennon O, Blake C, Nolan M, Barry S, Smith E, Maye F, Lynch J, O'Connor L, Maume L, Cheyne S, Ní Ghiollain S, Fullen BM. An internet-delivered cognitive behavioural therapy pain management programme for spinal cord injury pain: A randomized controlled trial. Eur J Pain. 2019 Aug;23(7):1264-1282. 
• Mehta, S., Hadjistavropoulos, H., Nugent, M. et al. Guided internet-delivered cognitive-behaviour therapy for persons with spinal cord injury: a feasibility trial. Spinal Cord 58, 544–552 (2020). 
• Mehta, S.H., Nugent, M., Peynenburg, V. et al. Internet-delivered cognitive behaviour therapy for chronic health conditions: self-guided versus team-guided. J Behav Med 45, 674–689 (2022). 

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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