Tackling the debilitating problems of chronic paining ...

The University of Sydney

Tackling the Debilitating

Problem of Chronic Pain

following SCI

John Walsh Centre for Rehabilitation Research, Sydney Medical School-Northern, Faculty of Medicine and Health, The Kolling Institute

Professor James Middleton


The problem of pain after SCI

▪ Chronic pain commonly accompanies SCI‒ present in about two-thirds, severe in one-third

▪ Contributes to poorer health and well-being, and reduced participation beyond SCI effects alone

▪ Significant negative impact on mood, sleep, daily activities, social integration & quality of life

… often difficult to manage despite many treatments.

Jensen et al, 2005; Middleton et al, 2007; Rintala et al, 1998; Westgren and Levi, 1998; Widerström-Noga et al, 2001.


The unwelcome house guest

“The most important thing to me is

to live my life and get out and

experience the things I have

always enjoyed in life… and not

be inhibited by serious pain... and

not let that control my life.“

(person with SCI)


C

Nerve Root Damage

Spinal Cord Damage

Brain changes

▪ Irritable focus with ectopic firing

▪ Increased excitability & central

sensitization

▪ Deafferentation & disinhibition

▪ Reorganisation with

“neuroplasticity”

Thalamus

S1 Cortex

SCI Pain Mechanisms


International SCI Pain Classification

SCI Pain

NociceptivePain

Musculo-skeletal

Pain

Visceral Pain

Neuropathic Pain

At-level Neuropathic

Pain

Below-level Neuropathic

Pain

Bryce et al., 2010

Other

Nociceptive

Other

Neuropathic


Nociceptive Pain Types

Image credit: http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain

Musculoskeletal Pain

• occurs in normally innervated regions above SCI

• acute pain from damage to bones, joints, discs,

ligaments, muscles) and/or instability

• chronic pain due to ‘overuse’ syndromes

• constant dull, ‘aching’ pain worse with movement

or posture

Visceral Pain

• located in the abdominal region

• often diffuse and dull (depending on lesion level)

• associated with inflammation, distension or

pathology in viscera (e.g., bladder and bowel)

• autonomic dysreflexia

• if investigations do not reveal obvious cause and

treatment unsuccessful neuropathic

http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain


Neuropathic Pain Types

Image credit: http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain

At-level Neuropathic Pain

• Radicular from nerve root/DRG – unilateral &

paroxysmal

• Central segmental cord damage – bilateral &

continuous

• dermatomal distribution in region of sensory loss

• burning, crushing, shooting, electric, stabbing

• allodynia or hyperaesthesia may be present.

Below-level Neuropathic Pain

• located below level (>3 dermatomes), diffuse, where sensory loss

• hot, burning, freezing, tingling, pins & needles, shooting, electric

• Spontaneous or evoked (e.g., by sudden noise, jarring)

• occasionally allodynia (incomplete injuries)

• bilateral, possibly unilateral.

Above-Level

http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain

http://www.carpaltunneltreatmenthq.com/natural-treatment


0

10

20

30

40

50

60

70

80

90

100

2 WKS 8 WKS 6 MTHS 5 YEARS

MUSCULOSKELETAL VISCERAL NEUROPATHIC (A) NEUROPATHIC (B) ANY PAIN

Prevalence of Pain after SCI

Siddall PJ, et al. Pain 2003; 103:249-257.


Aus-InSCI Results – Health Problems

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pain

Sexual…

Spasms

Sleep

Bowel

Bladder

Circulation

Pressure Injuries

Auton Dysreflexia

Respiratory

None Mild Moderate Severe Extreme


Aus-InSCI Results – Health Problems

• The most common health problem was pain (85%).

• Pain intensity was rated as high (mean 5±3/10),

with 39% reporting severe levels (VAS 7-10/10).

• High pain interference with activities (36.4%), mood

(33.8%) and sleep (37.4%).

• Treatments included opioids (18.5%), over-counter

medications (41.3%), anticonvulsants (34.3%),

marijuana (7.5%), alcohol (9.8%), physiotherapy

(20.1%), physical activity (32.7%) and

psychological support (6.5%).

Compared to 1 year ago, general health was rated as:

better in 23%, about same in 55% and worse in 22%.


Treatment - Musculoskeletal Pain

▪ Stabilisation procedures (spinal surgery, braces)

▪ Correct underlying contributing factors:

‒ Postural re-education, exercise & stretching

‒ Activity modification (to reduce mechanical loading),

pacing and use of adaptive equipment

‒ Seating & wheelchair biomechanics

Pharmacological treatment for symptom relief

▪ Simple analgesics, NSAIDs

▪ Opioids

▪ Baclofen, Diazepam, Tizanidine (spasm)

▪ Local joint steroid injections (eg. shoulder joint, bicipital

groove)


▪ Find (and treat) underlying cause – in first instance look

for genitourinary (infection, calculi, obstruction) or bowel-

related (constipation, impaction) pathology.

– Treat infections with antibiotics (eg. UTI, prostatitis)

– Surgical procedures (e.g., lithotripsy/paxy to remove

calculi / ureteric obstruction)

– Disimpaction, adjust bowel regimen/routine

▪ Other (e.g., gall stones, peptic ulcer, etc)

▪ Autonomic dysreflexia, which may be associated,

requires urgent attention.

➔ If no cause identified, treat as ?Neuropathic

Treatment - Visceral Pain


Pharmacological TreatmentNeuropathic Pain

First-line

– Commence an anticonvulsant (Pregabalin OR Gabapentin)

Add tricyclic antidepressant - Amitriptyline OR Nortriptyline


Response to Pregabalin in SCI Neuropathic Pain

Siddall et al Neurology 2006; 67: 1792-1800.

0

10

20

30

40

50

Placebo

(n=67)

Pregabalin

(n=69)%

of

pa

tie

nts

0

10

20

30

40

50

Placebo

(n=67)

Pregabalin

(n=69)

% o

f p

ati

en

ts

50% reduction

in pain score

30% reduction

Changes in pain scores

− Double-blind, placebo-controlled

study (n=137)

− Average dose = 460 mg/day

22%

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Week

Me

an

pa

in s

co

re

Placebo (n=67)

Pregabalin (n=69)

EP

*** ****** *** *** *** *** *** ** ** ** ** ***

** P<0.01, ***P<0.001 vs. placebo

7.5%

42%

16%


Pharmacological TreatmentNeuropathic Pain

First-line

– Commence an anticonvulsant (Pregabalin OR Gabapentin)

Add tricyclic antidepressant - Amitriptyline OR Nortriptyline

Second-line

– Weak opioid (Tramadol) - Nb. serotonergic syndrome

– SNRI (e.g., Duloxetine)

Third-line

– Opioids (Buprenorphine, Oxycodone, Morphine, Hydromorphone,

Fentanyl, Methadone)

▪ Spinal drug delivery (Morphine/Clonidine, Alfentanil)


SCI NP Pain & Medications

Opioids:

▪ Tolerance

▪ Potential abuse

▪ Hypersensitivity / “Hyperalgesia”.

THC:

▪ Mainly negative results from research

▪ Potential misuse, diversion and long-

term mental health risks

▪ Different preparations, with more to

learn about cannabis pharmacology.


Medications: Effects vs Side-effects

I used to take a lot of pain medication – it

was the only way I could take the edge

off. But it almost didn’t ease the pain – it

just made you care less about it!!

It took a long time to reduce the

medication, but now I’m not on any pain

medication and I’m much happier with

that, I have a clearer head and my

memory is improved! Some things early on

– I just can’t remember as a result of all

the medications.

Joe, incomplete paraplegia

EffectsSide-

Effects


The Biopsychosocial Model

Tissue damagePain ‘generator’

Pain perception

Emotional distress(suffering)

Coping and painbehaviour (disability)

Social environmentCulture/Sick role

Attitudes &Beliefs

After Loeser, 1982

Social

Psycho

Bio


Origins of Catastrophic Thought?


Treatment: Physical

▪ Equipment to reduce strain

▪ Environmental set up

▪ Regular gentle exercise

▪ Activity Plan

▪ Pacing Plan

▪ Flare Up Plan

http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain/spinal-cord-injury-pain-physical-activity-and-exercise


Time

Activity

Level

Pain, Pacing and Physical Activity

▪ Important to maintain a regular pattern of activity

despite pain.

▪ Use pacing principles to plan, chunk and gradually build

up activity to avoid the “boom and bust” cycle

www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain/spinal-crd-injury-

pain-physical-activity-and-exercise

Pain Flare

Pain Flare

Pain Flare

Pain Flare

Over-Doing it

Under-Doing it

http://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain/spinal-crd-injury-pain-physical-activity-and-exercise


Treatment: Psychological

▪ Includes a combination of:

‒ Relaxation

‒ Mindfulness / Meditation

‒ Distraction

‒ Managing your thoughts

‒ De-sensitisation

‒ Flare up plan

‒ Sleep strategies

▪ Thoughts and feelings can

influence the pain experience

▪ Can re-train the brain to reduce

the impact of pain on your life

“Everyone has a different way to

cope with the pain. I used a lot

of meditation early on and

desensitisation. Now I have

taught myself to play guitar,

and when I play it is like a

meditation for me.”


PAINLocated in a region of

normal sensation

Dull, aching pain

Related to posture,

activity, movement

Somatic tenderness

Vague, poorly localised,

cramping, intermittent

pain in thorax, abdomen

Related to visceral function

Antibiotics

Cystoscopy

Lithotripsy

Disempaction

Adjust bowel

aperients &

routine

Oral baclofen

Tizanidine

Diazepam

NOCICEPTIVE

VISCERALMUSCULO

SKELETAL

Acetaminophen

NSAIDs Botulinum

toxin (if focal

spasm)

Intrathecal

baclofen

Colonoscopy

Bowel transit

studies

Transanal

irrigation

Colostomy

Treat muscle imbalance, exercise

Postural reeducation, seating

Retrain transfer techniques

Address wheelchair

biomechanics

Activity pacing & modification

Environmental modifications

NEUROPATHIC

(see Figure 4)

-Nociceptive pain

indirectly related or

unrelated to SCI, such as

dysreflexic headache,

pressure areas, migraine

Electric shock, shooting,

squeezing, burning pain

Segmental pattern,

located at NLI and/or

within 3 dermatomes, or

involves cauda equina



Located more than 3

dermatomes below NLI

(but may include them)

BELOW-LEVEL

NEUROPATHICAT-LEVEL

NEUROPATHIC

OTHER

NOCICEPTIVE

- - -

Related to repetitive

movement

Local tenderness,

pain on stretching,

resisted movement

Neck or back pain

Kyphus / scoliosis

Worsens during day

Relieved by lying

Possible trigger pts

POOR POSTURE

& MECHANICS“OVERUSE

SYNDROME”

Increased

muscle tone

MUSCLE SPASM

--Fever, frequency,

urine leakage, debris,

blood, spasms, AD

WCC, urinalysis,

MCS, ultrasound, CT

Constipation,

diarrhoea, bloating

Worse after meal,

Improved by evacuation

Impacted on AXR

Pounding headache,

sweating, flushing,

blurred vision, etc

Elevated blood

pressure (>20mmHg)

-

PSEUDOBOWEL

OBSTRUCTIONINFECTION,

CALCULUS

AUTONOMIC

DYSREFLEXIA

--

-

Tramadol

“Strong” opioids

Located in a region of

impaired sensation

Spinal

fusion

Signs of instability

on examination

Structural changes

evident on imaging

FRACTURE

DISLOCATION

-Exclude pathology,

such as peptic ulcer,

gall stones, etc

on ultrasound, CT

scan, endoscopy

-

-

Identify and

treat cause

Identify and

treat cause

BP lowering

drugs

Further

investigatio

n

-

+++++

++ +++ + +

ALL - ASSESS AND TREAT PSYCHOSOCIAL & ENVIRONMENTAL CONTRIBUTORS - POOR PACING, UNHELPFUL COGNITIONS, MOOD DYSFUNCTION (e.g. CBT, Anxiolytics, Antidepressants)

- --

+ -

Siddall & Middleton. ISCoS Textbook on Comprehensive Management , Chapter 55, 2015.


Surgicaldecompression

Nerve conduction

studies

Electromyography

CT scan, MRI scan

Monitor

Shunting/

Detethering

Strong opioids (controversial)

Refer to Multidisciplinary Pain Service

Non-pharmacological approaches

(ie. stimulation, surgical, procedural

and psychological interventions

described in text)

Treat appropriate to

condition, eg. carpal

tunnel release,

neuropathic pain

medications

BELOW-LEVEL

NEUROPATHIC

AT-LEVEL

NEUROPATHIC

Unilateral distribution

correlates with nerve

root compression on

CT or MRI scan

NERVE ROOT

COMPRESSION

Ascending sensory

level, loss of muscle

strength, reflexes

Cystic cavity on MRI

SYRINX

-

Pregabalin / Gabapentin

+/-Tricyclic antidepressant

Tramadol (with

anticonvulsant)

Replace TCA with SNRI

a

-

-

-

-


normal sensation

NOCICEPTIVE

(see Figure 3)

MUSCULO

SKELETAL

NEUROPATHIC

-Nociceptive pain

indirectly related or

unrelated to SCI, such as

dysreflexic headache,

pressure areas, migraine



Segmental pattern,

located at NLI and/or

within 3 dermatomes, or

involves cauda equina



Located more than 3

dermatomes below NLI

(but may include them)

-


impaired sensationPAIN-

OTHER

NOCICEPTIVE

Dull, aching pain

Related to posture,

activity, movement

Somatic tenderness

Vague, poorly localised,

cramping, intermittent

pain in thorax, abdomen

Related to visceral function

VISCERAL

-

ALL - ASSESS AND TREAT PSYCHOSOCIAL & ENVIRONMENTAL CONTRIBUTORS - POOR PACING, UNHELPFUL COGNITIONS, MOOD DYSFUNCTION (e.g. CBT, Anxiolytics, Antidepressants)

OTHER

NEUROPATHIC

Neuropathic pain indirectly

related or unrelated to SCI,

such as carpal tunnel

syndrome, postherpetic

neuralgia

+

++

+ ++++

+

Siddall & Middleton. ISCoS Textbook on Comprehensive Management , Chapter 55, 2015.


ACI Pain Website – Spinal Page

Consumer Resources

8 Key Topic Areas:

Introduction to SCI and Chronic Pain

Understanding Pain after SCI

Getting help from your health care team

SCI Pain, Physical Activity and Exercise

Pain: Lifestyle and Nutrition

Medications for SCI Pain

SCI Pain: Thoughts and Feelings

Pain and Sleep

http://www.aci.health.nsw.gov.au/chronic-pain


▪ Screening – activates tool

▪ Pain Assessment:

‒ Pain severity & interference

‒ Pain location (in relation to SCI level)

‒ Pain features & type

‒ Aggravating / easing factors

‒ Treatment & medication details

▪ Red Flags

▪ Yellow Flags

▪ Treatment – Pain Management Plan

▪ Referrals

▪ Resources

Clinical Decision-Support Tool

http://www.aci.health.nsw.gov.au/chronic-pain


Clinical Decision-Support Tool

https://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain

https://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain


Quicksteps

https://www.aci.health.nsw.gov.au/chronic-pain/health-professionals/spinal-cord-injury-pain-quick-steps




Quicksteps


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