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As outlined previously, managing chronic pain has been reported as one of the most critical 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 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 pharmacological treatment options of pregabalin, gabapentin or amitriptyline for managing neuropathic pain after SCI. These guidelines also include a list of non-pharmacological secondary treatments, acknowledging that these options have various levels of evidence or strength of recommendation. With this understanding, clinicians are encouraged to make suggestions for these secondary treatment options based on other relevant factors, including patient preference, clinician experience, accessibility, side-effects and tolerance. Neuromodulation through Spinal Cord Stimulation (SCS) is recommended under the secondary treatment options for consideration in the management of chronic pain after SCI.

Neuromodulation is the alteration of nerve activity by the process of electrically stimulating the dorsal column in the spinal cord, with the goal of masking pain signals. When referring to electrical stimulation of the spinal cord it is important to differentiate between transcutaneous stimulation – a temporary application of electrodes to the skin over the spinal cord, and epidural stimulation - a more permanent and invasive therapy.  While both transcutaneous and epidural spinal stimulation have been utilized for neurorecovery, in this edition we will be exploring pain neuromodulation through epidural SCS. 

Spinal Cord Stimulators consist of a small pacemaker sized generator implanted in the abdomen or flank, connected to thin electrodes which are fed up into the mid-thoracic epidural area of the spine. The individual can then activate the Stimulator by a hand-held remote control with pre-programed settings. Some SCS devices use a low-frequency current which is meant to replace the pain sensation with a mild tingling feeling – paresthesia – while other devices will use a higher-frequency to try to mask the sensation of pain. It is important to realize that SCS does not eliminate the source of pain, but rather it changes the way the brain perceives the sensation. As a result, the goal for SCS is a 50 - 70% reduction in pain, which is significant if it reduces the amount of pain medication needed and helps the individual perform daily activities, return to work or participate in leisure activities.

The success of SCS depends on careful patient selection, with a multidisciplinary medical and psychological assessment to confirm that an individual is a good candidate. After this, a trial period of SCS begins to determine the effectiveness of the intervention for managing the individual’s pain, before considering a more permanent implantation. During this trial, the individual is encouraged to maintain their regular activities, and continue their current treatments for pain management – both pharmacological and non-pharmacological. After monitoring and adjusting the settings during the trial, the individual and the team will decide on the advantages of a more permanently implanted SCS system.  

Learn more about the work being done with SCS to promote neuro-recovery for individuals with SCI - Praxis - Spinal Cord Stimulation Landscape.

Clinical Trials:

• 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
• Dr Andrei Krassioukov is investigating noninvasive spinal cord stimulation for recovery of autonomic function after spinal cord injury. Click here to learn more.

For a complete list of trials click here

General Resources:

• In an interview with CBC in 2019, Dr. Osborn explains that SCS plays a big part in reducing opioids needed to manage pain. Read article

Videos:

• Canadian Spinal Cord Stimulation Interest Group Meeting – Lived Experience Panel Watch here
• CNN: New Spinal Cord Stimulation study puts people with paralysis on their feet again Watch here

Articles: 

• Laskin et al., Spinal Cord Stimulation Research in the Restoration of Motor, Sensory, and Autonomic Function for Individuals Living With Spinal Cord Injuries: 2018 
• Caylor J, et al., Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action 2019
• Huang Q, et al., Spinal Cord Stimulation for Pain Treatment After Spinal Cord Injury. 2018
• Hong et al., Spinal cord stimulation: a nonopioid alternative for chronic pain management: 2020

Technology:

• Still an investigational device, undergoing several clinical trials, ONWARD’S ARC Therapy is being designed to deliver targeted, programed stimulation of the spinal cord. 

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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