Phenotypes and predictors of pain following traumatic spinal cord injury: a prospective study. A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury Pain following spinal cord injury Secondary conditions following spinal cord injury in a population-based sample The CONECSI trial: Results of a randomized controlled trial of a multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain after spinal cord injury Chronic pain/dysaesthesiae in spinal cord injury patients: results of a multicentre study A Review of Clinical Trials in Spinal Cord Injury Including Biomarkers. A comparison of posttraumatic stress disorder in veterans with and without spinal cord injury. Anxiety and depression after spinal cord injury: a longitudinal analysis. Chapter 46 Pain following spinal cord injury. Longstanding neuropathic pain after spinal cord injury is refractory to transcranial direct current stimulation: A randomized controlled trial Long-term outcomes of a multidisciplinary cognitive behavioural programme for coping with chronic neuropathic spinal cord injury pain. Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress and pain Spinal cord injury: a search for determinants of depression two years after the event. A prospective assessment of mortality in chronic spinal cord injury Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury—results from a seated double-poling ergometer study Neuropathic pain post spinal cord injury part 1: systematic review of physical and behavioral treatment.
UNLABELLED Pain is a serious consequence of spinal cord injury ( SCI ) . Our aim was to investigate the temporal aspects of different types of pain following traumatic SCI and to determine possible predictors of neuropathic pain . Prospect i ve data on 90 patients were collected at 1 , 6 , and 12 months after traumatic SCI . The patients completed question naires on pain severity , descriptors , and impact and underwent clinical examination with bedside sensory testing .  Eighty-eight patients completed the 12-month follow-up . Approximately 80 % of patients reported any type of pain at all 3 time points . Neuropathic pain related to SCI increased over time , and musculoskeletal pain decreased slightly , with both being present in 59 % of patients at 12 months ; other neuropathic pain not related to SCI and visceral pain were present in 1 to 3 % . At-level neuropathic pain present at 1 month resolved in 45 % and below-level pain resolved in 33 % . Early ( 1 month ) sensory hypersensitivity ( particularly cold-evoked dysesthesia ) was a predictor for the development of below-level , but not at-level , SCI pain at 12 months . In conclusion , the present study demonstrates phenotypical differences between at-level and below-level SCI pain , which is important for future studies aim ing to uncover underlying pain mechanisms . PERSPECTIVE The finding that early sensory hypersensitivity predicts later onset of below-level central neuropathic pain may help to identify patients at risk of developing neuropathic pain conditions after traumatic spinal cord injury . Information about onset of pain may help to identify different phenotypes in neuropathic pain conditions & NA ; A longitudinal cohort study of 100 people with traumatic spinal cord injury ( SCI ) was performed to determine the prevalence and severity of different types of pain ( musculoskeletal , visceral , neuropathic at‐level , neuropathic below‐level ) at 5 years following SCI . Prospect i ve data on the characteristics of pain up to 6 months following injury had been collected previously and allowed comparisons between the presence of pain at different time points . In addition , we sought to determine the relationship between the presence of pain and physical factors related to the injury such as level of lesion , completeness and clinical SCI syndrome . We also obtained information regarding mood , global self‐rated health and the impact of pain on function . Of the 100 subjects in the original cohort , 73 were available for follow up . When all types of pain were included , 59 of the 73 subjects ( 81 % ) reported the presence of pain . Musculoskeletal pain was the most common type of pain experienced and was present in 43 subjects ( 59 % ) , at‐level neuropathic pain was present in 30 subjects ( 41 % ) , below‐level neuropathic pain was present in 25 subjects ( 34 % ) and visceral pain was present in four subjects ( 5 % ) . Overall , 58 % reported their pain as severe or excruciating and those with visceral pain were most likely to rate their pain in these categories . There was no relationship between the presence of pain overall and level or completeness of lesion , or type of injury . However , tetraplegics were more likely to report below‐level neuropathic pain . This study prospect ively demonstrates the differing time courses of different types of pain over the first 5 years following SCI . There was a strong correlation between the presence of both types of neuropathic pain at 5 years and earlier time points but both visceral pain and musculoskeletal pain demonstrated a poor correlation between time points . Chronic visceral pain occurs in a small percentage of patients and does not correlate with the presence of visceral pain early following injury . Those with neuropathic pain early following their injury are likely to continue to experience ongoing pain and the pain is likely to be severe . In contrast , chronic musculoskeletal pain is more common but less likely to be severe and can not be predicted by the presence of pain in the first 6 months following injury Some patients with spinal cord injury ( SCI ) complain of severe pain . The purpose of this study was to investigate the prevalence and classification of SCI-related pain , in terms of severity , location , aggravating and alleviating factors . 47 SCI individuals were studied between 15 and 67 years of age . Sixty-one percent of subjects experienced pain of moderate to severe intensity . 32 subjects complained of pain in the lower limbs , five patients had pain in the visceral region , eight in the pelvic and perineal areas . The pain duration was for a median of 5 weeks . The patients with pain were older ( median 41 years ) than those without pain ( median 23 years ) .  Pain was reported to be more intense in the evening and at night . The incidence of pain was higher in patients with thoracolumbar and incomplete spinal cord lesions .  Inactivity , stress , weather change , overactivity were identified as aggravating factors . Sleep and rest were demonstrated as alleviating factors This prospect i ve study investigates the frequency of both medical and non-medical complications reported by the population based cohort of SCI survivors reported to the Colorado Spinal Cord Injury Early Notification System ( ENS ) . Persons reported to the ENS between January 1 1986 and December 31 1993 , representing the broad spectrum of all severities of spinal cord injury and potential complications , were solicited to participate in comprehensive follow-up interviews at their first , third and fifth year post injury . Hospitalizations of a week or longer were experienced by more than 10 % of the participants at each of the three interview years . Similarly , the medical complications of spasticity or pain were reported by more than 25 % of the participants , and pressure sores were reported by more than 10 % at all three time periods . The chief non-medical complications ( conditions ) were financial concerns and transportation problems . Although these reported medical and non-medical complications present significant obstacles to be overcome , less than three percent of those surveyed at any of the time periods reported experiencing depression ; and only 14 % rated their quality of life as being poor Summary A multidisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic spinal cord injury pain . ABSTRACT Many people with spinal cord injury ( SCI ) rate chronic neuropathic pain as one of the most difficult problems to manage . The aim of the CONECSI ( COping with NEuropathiC Spinal cord Injury pain ) trial was to evaluate a multidisciplinary cognitive behavioral treatment program for persons with chronic neuropathic pain after SCI . The intervention consisted of educational , cognitive , and behavioral elements .  A total of 61 people were r and omized to either the intervention group or the waiting list control group in 4 Dutch rehabilitation centers . Primary outcomes were pain intensity and pain‐related disability ( Chronic Pain Grade question naire ) , and secondary outcomes were mood ( Hospital Anxiety and Depression Scale ) , participation in activities ( Utrecht Activities List ) , and life satisfaction ( Life Satisfaction Question naire ) . Measurements were performed at baseline , and at 3 , and 6 months follow‐up . The primary statistical technique was r and om coefficient analysis . The analyses showed significant changes over time on both primary ( t1–t2 ) , and 2 out of 4 secondary outcomes ( both t1–t2 and t1–t3 ) . Significant intervention effects ( Time * Group interactions ) were found for anxiety and participation in activities , but not for the primary outcomes . Subsequent paired t tests showed significant changes in the intervention group that were not seen in the control group : decrease of pain intensity , pain‐related disability , anxiety , and increase of participation in activities . This study implies that a multidisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic SCI pain The aim of the multicentre study * entitled ` Description and Documentation of Painful States in Spinal Cord Injury Patients ' , in addition to the description and documentation of chronic pain and stressful dysaesthesiae in SCI patients , was the search for correlations between these symptoms and medical and psychosocial variables . To this end , the sample was selected to be as representative as possible . All patients referred for in-patient or out-patient treatment at the centres taking part were enrolled in the study in order of presentation , providing they gave consent and met the inclusion criteria . Psychosocial , medical and demographic data were elicited by a st and ardized battery of questions and a st and ardized physical examination , as were any chronic pain/dysaesthesiae ( P/D ) present in any localization . Among 901 patients , 34 % had no chronic pain or dysaesthesiae , 50 % had pain only , 11 % had painful dysaesthesiae and 5 % , non-painful but chronic and distressing dysaesthesiae . The intensity of P/D was noted as seven or more on a 10 cm visual analogue scale by 61 % of the patients affected and was experienced as rather or very distressing in 75 % of cases . Most ( 86 % ) P/D were located below the spinal lesion or in the transition zone . There were significant correlations between the presence of P/D and age on question ing and at onset of the paraplegia/tetraplegia , problems with rectal paralysis , expectations of life as a paraplegic/tetraplegic , and subjective assessment of changes in working life . Highly significant correlations were found with subjective distress result ing of paraplegia/tetraplegia as such , depressed mood and psychosomatic disturbances of wellbeing . Overall , among the selected variables of our study , we found that correlations between P/D and psychosocial variables were more frequent and closer than those between P/D and medical variables Acute traumatic spinal cord injury ( SCI ) entered the arena of prospect i ve , r and omized clinical trials almost 40 years ago , with the undertaking of the National Acute Spinal Cord Study ( NASCIS ) I trial . Since then , a number of clinical trials have been conducted in the field , spurred by the devastating physical , social , and economic consequences of acute SCI for patients , families , and society at large . Many of these have been controversial and attracted criticism . The current review provides a critical summary of select past and current clinical trials in SCI , focusing in particular on the findings of prospect i ve , r and omized controlled trials , the challenges and barriers encountered , and the valuable lessons learned that can be applied to future trials The authors assessed effects of  paraplegic and quadriplegic spinal cord injuries ( SCIs )  on posttraumatic stress disorder ( PTSD ) by comparing severity and prevalence of PTSD in these groups to a sample of controls who experienced traumatic injuries other than SCI . The authors found that veterans with quadriplegia reported significantly less severe current PTSD symptoms than controls who were not significantly different from veterans with paraplegia . These results suggest that sustaining a quadriplegic SCI decreases risk of current PTSD , whereas sustaining a paraplegic SCI is associated with greater risk of PTSD , although the risk is no greater than that incurred from experiencing the trauma itself OBJECTIVE To examine the prevalence of anxiety and depression longitudinally in a sample of patients with a spinal cord injury ( SCI ) . DESIGN A prospect i ve , longitudinal , multiple wave panel design with measures taken on 14 observational periods ranging from initial contact in the acute stages of hospitalization to 2 years ' postdischarge to the community . SETTING The National Spinal Injuries Centre , Stoke M and eville Hospital , Aylesbury , UK , and the general community . PARTICIPANTS The cohort consisted of 104 patients with traumatic SCI ( 19 women , 85 men ) , although the numbers assessed at each interval ranged from 5 to 85 . MAIN OUTCOME MEASURES Measures included the Beck Depression Inventory , the Beck Hopelessness scale , the State Anxiety Inventory , the functional independence measure , and the Social Support Question naire . RESULTS When examined longitudinally , the data illustrate a consistent pattern of results across measures , with scores highest in the acute phase of the injury and during the months leading up to discharge . CONCLUSION The numbers of persons scoring above clinical cut-off scores for anxiety and depression highlight the need to continue to ensure that appropriate psychological care is available within SCI rehabilitation setting s. Moreover , the nature of the longitudinal results provides an indicator of subtle changes in anxiety and depression over time Publisher Summary This chapter explores that spinal cord injury ( SCI ) has a number of severe and disabling consequences . Although loss of function is often considered the primary issue , pain is also a major problem . In central pain conditions , small r and omized trials have shown the effectiveness of amitriptyline and lamotrigine in central post-stroke pain and of dronabinol , a cannabinoid , in pain in multiple sclerosis . It is not known whether the efficacy of drugs in other central or peripheral neuropathic pain conditions can be anticipated to have similar effects in SCI neuropathic pain . Central neuropathic pain is often considered more refractory than peripheral neuropathic pain . It has been suggested that central post-stroke pain responds better to antidepressants than SCI pain . The chapter also review s that because of the lack of sufficient data in neuropathic SCI pain , efficacy in other neuropathic pain conditions has to be considered in choosing treatment Summary In a r and omized sham‐controlled crossover study , transcranial direct current stimulation over the primary motor cortex did not provide relief for long‐st and ing neuropathic spinal cord injury pain . Abstract Neuropathic pain remains one of the most difficult consequences of spinal cord injury ( SCI ) to manage . It is a major cause of suffering and adds to the physical , emotional , and societal impact of the injury . Despite the use of the best available treatments , two thirds of people experiencing neuropathic pain after SCI do not achieve satisfactory pain relief . This study was undertaken in response to a recent clinical trial reporting short‐term , clinical ly significant reductions in neuropathic SCI pain with primary motor cortex transcranial direct current stimulation ( tDCS ) . In this investigation , we aim ed to build on this previous clinical trial by extending the assessment period to determine the short‐ , medium‐ , and long‐term efficacy of tDCS for the treatment of neuropathic pain after SCI . We found that , contrary to previous reports , after 5 tDCS treatment periods , mean pain intensity and unpleasantness rating were not significantly different from initial assessment . That is , in this trial tDCS did not provide any pain relief in subjects with neuropathic SCI pain ( n = 10 ) . A similar lack of effect was also seen after sham treatment . Because the injury duration in this study was significantly greater than that of previous investigations , it is possible that tDCS is an effective analgesic only in individuals with relatively recent injuries and pain . Future investigations comparing a range of injury duration s are required if we are to determine whether this is indeed the case OBJECTIVE To explore the long-term outcomes of CONECSI ( COping with NEuropathiC Spinal cord Injury pain ) , a multidisciplinary cognitive behavioural treatment programme in persons with spinal cord injury . DESIGN Long-term follow-up pre-post-intervention design . SUBJECTS A total of 29 subjects with a spinal cord injury and chronic neuropathic pain from 4 Dutch rehabilitation centres . METHODS Primary outcomes were pain intensity and pain-related disability ( Chronic Pain Grade question naire ) . Secondary outcomes were mood ( Hospital Anxiety and Depression Scale ) , participation in activities ( Utrecht Activities List ) , and life satisfaction ( Life Satisfaction Question naire ) . R and om coefficient analysis was used for the analyses of measurements before ( t1 ) , immediate post-intervention ( t2 ) , and 6 ( t3 ) , 9 ( t4 ) , and 12 ( t5 ) months follow-up . RESULTS The analyses showed significant improvements on pain intensity ( t1-t2 and t1-t5 ) and pain-related disability ( t1-t2 , t1-t4 , and t1-t5 ) , anxiety and participation in activities ( t1-t2 , t1-t3 , and t1-t5 ) . CONCLUSION This exploratory study suggests that a multidisciplinary cognitive behavioural programme might have lasting improvements on pain intensity , pain-related disability , anxiety , and participation in activities in people with chronic neuropathic spinal cord injury pain and highlights the potential of such programmes Study design : Follow-up study of seven individuals with spinal cord injury ( SCI ) who completed a 9-month r and omized control trial ( RCT ) of exercise training .  Objective : In a 9-month RCT conducted in our lab , individuals with SCI who participated in a twice-weekly supervised exercise training reported greater perceived quality of life ( PQOL ) , and less stress and pain than a nonexercising control cohort . The present follow-up study examined the voluntary continuation of exercise training after the study ended and the persistence of the accrued psychosocial benefits . Setting : Centre for Health Promotion and Rehabilitation , McMaster University , Hamilton , Ontario , Canada . Methods : Five men and two women ( age 42.3±3.6 years ) with SCI ( C5–T12 ; ASIA A – D 12.7±8.2 years postinjury ) were invited to continue supervised exercise training twice weekly at the completion of the 9-month RCT . Exercise adherence , PQOL , stress and bodily pain were measured at a 3-month follow-up and were compared to values obtained at baseline , and at 3 , 6 and 9 months during the intervention . Results : There was a significant decrease in adherence at the 3-month follow-up compared to the overall 9-month adherence rate ( 42.7 versus 80.6 % , respectively ; P<0.01 ) . There was also a significant decrease in PQOL ( P<0.05 ) and a trend for increased pain ( P=0.07 ) and stress ( P=0.12 ) , at follow-up compared to the end of the 9-month trial . Finally , there was a significant negative correlation between pain at the conclusion of the RCT and exercise adherence over the 3-month follow-up period ( r=−0.91 ; P<0.01 ) . Conclusions : These findings emphasize the importance of continued exercise adherence to the maintenance of exercise-related increases in psychological well-being among individuals with SCI A prospect i ve longitudinal study employing repeated measures was used to isolate factors which might predispose a person to depression two years after sustaining spinal cord injury ( SCI ) . Thirty-one subjects who suffered acute spinal injuries result ing in permanent loss of movement , and who had no head injuries or any pre-existing psychopathology , were at least 17 years of age , and who were able to speak English , participated in the study . Using the Beck Depression Inventory ( BDI ) as a measure of depression , a regression analysis demonstrated that the experience of pain two years post-injury and feeling out of control of one 's life prior to hospital discharge were predictive of depression two years post-injury . No demographic variables or injury characteristics such as level of lesion or completeness of lesion were related to long-term depression .  Pain management and rehabilitation techniques that enhance the individual 's belief of control over their lives are therefore recommended as interventions that could act to reduce depression in the long term in persons with spinal cord injury Study design : Prospect i ve mortality study . Objective : To assess the relationship between comorbid medical conditions and other health-related factors to mortality in chronic spinal cord injury ( SCI ) . Setting : Boston , MA , USA . Methods : Between 1994 and 2000 , 361 males ⩾1 year after injury completed a respiratory health question naire and underwent pulmonary function testing  . Cause-specific mortality was assessed over a median of 55.6 months ( range 0.33–74.4 months ) through 12/31/2000 using the National Death Index . Results : At entry , mean ( ±SD ) age was 50.6±15.0 years ( range 23–87 ) and years since injury was 17.5±12.8 years ( range 1.0–56.5 ) . Mortality was elevated ( observed/expected deaths=37/25.1 ; SMR=1.47 ; 95 % CI=1.04–2.03 ) compared to US rates . Risk factors for death were diabetes ( RR=2.62 ; 95 % CI=1.19–5.77 ) , heart disease ( RR=3.66 ; 95 % CI=1.77–7.78 ) , reduced pulmonary function , and smoking . The most common underlying and contributing causes of death were diseases of the circulatory system ( ICD-9 390–459 ) in 40 % , and of the respiratory system in 24 % ( ICD-9 460 - 519 ) . Conclusions : These results suggest that much of the excess mortality in chronic SCI is related to potentially treatable factors . Recognition and treatment of cardiovascular disease , diabetes , and lung disease , together with smoking cessation may substantially reduce mortality in chronic SCI Objectives : To assess pain relieving effects of an intensive exercise programme on a seated double-poling ergometer in individuals with spinal cord injury ( SCI ) . Setting : Stockholm , Sweden . Methods : A total of 13 wheelchair-dependent individuals with a thoracic or lumbar SCI were recruited to a 10-week training period ( three times weekly ) assessing the effects of regular training on upper-body strength , aerobic and mechanical power , and crossover effects on functional performance , as well as cardiovascular risk factors . Eight of the participants reported pain and were included in this exploratory pain protocol and assessed using the International SCI Basic Pain Data set , the Wheelchair Users ’ Shoulder Pain Index and International SCI Quality of Life Basic Data set . Results : For those with neuropathic pain , median pain intensity ratings decreased from 5 on a 0–10 numerical rating scale at base-line to 3 at the end of study , and four of seven participants reported an improvement on the Patient Global Impression of Change scale . For those with musculoskeletal pain ( n=5 ) , median pain intensity ratings improved from 4 at baseline to 0 at the end of study . All but one rated no musculoskeletal pain at all at the end of study and number of days with pain per week decreased from 5.5 to 0.7 . None of the participants developed pain , because of overuse during the training period and few reported unwanted side effects . Conclusion : Considering its promising effects and safety , an intensive exercise programme can be tried for treating musculoskeletal pain and also neuropathic pain following SCI BACKGROUND Neuropathic pain has various physiologic and psychosocial aspects . Hence , there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury ( SCI ) . OBJECTIVE The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI . METHODS MEDLINE , CINAHL , EMBASE , and PsycINFO data bases were search ed for articles addressing nonpharmacological treatment of pain post SCI . Articles were restricted to the English language . Article selection was conducted by 2 independent review ers with the following inclusion criteria : the subjects participated in a treatment or intervention for neuropathic pain ; at least 50 % of the subjects had an SCI ; at least 3 subjects had an SCI ; and a definable intervention was being studied . Data extracted included study design , study type , subject demographics , inclusion and exclusion criteria , sample size , outcome measures , and study results . R and omized controlled trials ( RCTs ) were assessed for quality using the Physiotherapy Evidence Data base ( PEDro ) assessment scale . Levels of evidence were assigned to each intervention using a modified Sackett scale . RESULTS The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI : physical and behavioral treatments . The pooled sample size of all studies included 433 participants . Of the 16 studies included , 7 were level 1 , 3 were level 2 , and 6 were level 4 studies . CONCLUSIONS Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain . Of these interventions , transcranial electrical stimulation had the strongest evidence of reducing pain . Despite a growing body of literature , there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain
The reported rate did not appear to be related to study quality .
Pain prevalence in the combined sample s did not appreciably differ between males and females , those with complete versus incomplete SCI , and those with paraplegia versus tetraplegia .
We conclude that too much heterogeneity was present in the reports to calculate a post-SCI pain prevalence rate using meta-analytic methods .
Published studies have reported widely divergent estimates of the prevalence of chronic pain among individuals with ( traumatic ) spinal cord injury ( SCI ) .