5. Assessment of Pain in SCI Patients

Actionable Nuggets for SCI (3rd ed., 2016)

Distinguish between neuropathic and musculoskeletal pain in your patient with SCI, and monitor pain regularly.

The Problem:

Between 48 and 94% of individuals with spinal cord injury (SCI) experience chronic pain. SCI-related pain is challenging to diagnose, because as many as eight different types of pain may occur alone or in combination, even at the same location. SCI pain can be broadly classified as either neuropathic or musculoskeletal. Often both types of pain co-exist in this population. Implications for management differ significantly depending on the origin of pain.

Evidence-based Best Practice:

People with SCI live with many questions regarding their pain, and with a sense that no one adequately understands their pain, including their family physician. The most commonly used measure of pain — the 10-point visual analogue scale (VAS) — is inadequate to capture the complexity of SCI pain. In order to obtain a comprehensive evaluation of SCI pain, the following dimensions should be evaluated: site, frequency, intensity, duration, pain quality or characteristics, timing, and interference with function.

The DN4 (Douleur Neuropathique en 4 Questions) is a screening tool that has been shown to distinguish well between neuropathic and musculoskeletal pain, and to have superior validity, sensitivity and specificity. Using the cut-off score of 4/10, the DN4 shows 83% sensitivity and 90% specificity (see attached).

Key Reference:

    Saulino, M. (2014). Spinal Cord Injury Pain. Physical Medicine and Rehabilitation Clinics of North America, 25(2), 384–391. http://doi.org/10.1016/j.pmr.2014.01.002

Additional References (chronological listing):

    Bryce, T., Richards, J., & Bombardier, C. (2014). Screening for neuropathic pain after spinal cord injury with the Spinal Cord Injury Pain Instrument (SCIPI): a preliminary validation study. Spinal Cord, 52(5), 407–12. http://doi.org/10.1038/sc.2014.21
    Felix, E. R. (2014). Chronic neuropathic pain in SCI. Evaluation and treatment. Physical Medicine and Rehabilitation Clinics of North America, 25(3), 545–571. http://doi.org/10.1016/j.pmr.2014.04.007
    Miró, J., Gertz, K. J., Carter, G. T., & Jensen, M. P. (2014). Pain Location and Functioning in Persons With Spinal Cord Injury. Physical Medicine and Rehabilitation, 6(8), 690-697. http://doi.org/10.1016/j.pmrj.2014.01.010
    Celik, C., Boyaci, S., & Ucan, H. (2013). Pain in patients with traumatic spinal cord injury. Journal of Musculoskeletal Pain.21 (1) ()(pp 53-57), 2013.Date of Publication: March 2013., 2452(1), 53–57. http://doi.org/10.3109/10582452.2013.770422
    Finnerup, N. B. (2013). Pain in patients with spinal cord injury. Pain, 154(SUPPL. 1), S71–S76. http://doi.org/10.1016/j.pain.2012.12.007
    Nakipoglu-Yuzer, G. F., Atçı, N., & Ozgirgin, N. (2013). Neuropathic pain in spinal cord injury. Pain Physician, 16(3), 259–64. http://www.ncbi.nlm.nih.gov/pubmed/23703412
    Bryce, T. N., Biering-Sørensen, F., Finnerup, N. B., Cardenas, D. D., Defrin, R., Ivan, E., … Dijkers, M. (2012). International Spinal Cord Injury Pain (ISCIP) Classification: Part 2. Initial validation using vignettes. Spinal Cord, 50(6), 404–412. http://doi.org/10.1038/sc.2012.2
    Celik, E.C., Erhan, B., & Lakse, E. (2012). The clinical characteristics of neuropathic pain in patients with spinal cord injury. Spinal Cord, 50: 585-89.
    Finnerup, N. B., & Baastrup, C. (2012). Spinal cord injury pain: mechanisms and management. Current Pain and Headache Reports, 16(3), 207–16. http://doi.org/10.1007/s11916-012-0259-x
    Spallone, V., Morganti, R., D’Amato, C., Greco, C., Cacciotti., L., & Marfia, G.A. (2012). Validation of DN4 as a screening tool for neuropathic pain in painful diabetic polyneuropathy. Diabetic Medicine, 29(5): 578-85.
    Spyridonis, F., Gawronski, J., Ghinea, G., & Frank, A.O. (2012). An interactive 3-D application for pain management: Results from a pilot study in spinal cord injury rehabilitation. Computer Methods and Programs in Biomedicine, 108(1), 356–66. http://doi.org/10.1016/j.cmpb.2012.02.005
    Furlan, J.C., Noonan, V., Singh, A, & Fehlings, M.G. (2011). Assessment of impairment in patients with acute traumatic spinal cord injury: A systematic review of the literature. Journal of Neurotrauma, 28, 1445-47.
    Haanpaa, M. (2011). Are neuropathic pain screening tools useful for patients with spinal cord injury? Pain, 152(2011), 715-16.
    Hallstrom, H., & Norrbrink, C. (2011). Screening tools for neuropathic pain: Can they be of use in individuals with spinal cord injury? Pain, 152(2011), 772-79.
    Jensen, M. P., Moore, M. R., Bockow, T. B., Ehde, D. M., & Engel, J. M. (2011). Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. Archives of Physical Medicine & Rehabilitation, 92(1), 146-160.
    Lin, C. P., Kupper, A. E., Gammaitoni, A. R., Galer, B. S., & Jensen, M. P. (2011). Frequency of chronic pain descriptors: Implications for assessment of pain quality. European Journal of Pain, 15(6), 628–633. http://doi.org/10.1016/j.ejpain.2010.11.006
    Jensen, M.P., Widerstrom-Noga, E., Richards, J.S., Finnerup, N.B., Biering-Sorensen, F., & Cardenas, D.D. (2010). Reliability and validity of the International Spinal Cord Injury Basic Pain Data Set items as self-report measures. Spinal Cord, 48(3), 230-8.
    Modirian, E., Pirouzi, P., Soroush, M., Karbalaei-Esmaeili, S., Shojaei, H., & Zamani, H. (2010). Chronic pain after spinal cord injury: results of a long-term study. Pain Medicine, 11(7), 1037-1043.
    Norman, C., Bender, J.L., Macdonald, J., Dunn, M., Dunne, S., Siu, B., Hitzig, S.L., et al. (2010). Questions that individuals with spinal cord injury have regarding their chronic pain: a qualitative study. Disability Rehabilitation, 32(2), 114-24.
    Cardenas, D. D., & Felix, E. R. (2009). Pain after Spinal Cord Injury: A Review of Classification, Treatment Approaches, and Treatment Assessment. Physical Medicine and Rehabilitation, 1(12), 1077-1090.
    Cruz-Almeida, Y., Felix, E. R., Martinez-Arizala, A., & Widerstrom-Noga, E. G. (2009). Pain symptom profiles in persons with spinal cord injury. Pain Medicine, 10(7), 1246-1259.
    De Miguel, M., & Kraychete, D. C. (2009). Pain in patients with spinal cord injury: A review.. Revista Brasileira de Anestesiologia, 59(53), 350-357.
    Dijkers, M., Bryce, T., & Zanca, J. (2009). Prevalence of chronic pain after traumatic spinal cord injury: a systematic review. Journal of Rehabilitation Research & Development, 46(1), 13-29. http://www.rehab.research.va.gov/jour/09/46/1/absdijkers.html
    Felix, E. R., & Widerstrom-Noga, E. G. (2009). Reliability and validity of quantitative sensory testing in persons with spinal cord injury and neuropathic pain. Journal of Rehabilitation Research & Development, 46(1), 69-83.
    Goossens, D, Dousse, M., Ventura, M., & Fattal, C. (2009). Chronic neuropathic pain in spinal cord injury patients: What is the impact of social and environmental factors on care management? Annals of Physical and Rehabilitation Medicine, 52(2), 173-9.
    Margot-Duclot, A., Tournebise, H., Ventura, M., & Fattal, C. (2009). What are the risk factors of occurrence and chronicity of neuropathic pain in spinal cord injury patients? Annals of Physical and Rehabilitation Medicine, 52(2), 111-23.
    Masson, E. (2009). Chronic neuropathic pain in spinal cord injury patients: What is the impact of social and environmental factors on care management? Annals of Physical and Rehabilitation Medicine, 52(2), 173-179.
    Widerstrom-Noga, E. G., Cruz-Almeida, Y., Felix, E. R., & Adcock, J. P. (2009). Relationship between pain characteristics and pain adaptation type in persons with SCI. Journal of Rehabilitation Research & Development, 46(1), 43-56.
    Finnerup, N.B., et al. (2008). Abdominal pain in long-term spinal cord injury. Spinal Cord, 46(3), 198-203. http://dx.doi.org/10.1038/sj.sc.3102097
    Sawatzky, B., et al. (2008). Classification and measurement of pain in the spinal cord-injured population. Spinal Cord, 46(1), 2-10. http://dx.doi.org/10.1038/sj.sc.3102137
    Ullrich, P.M., Jensen, M.P. Loeser J.D., & Cardenas, D.D. (2008). Pain intensity, pain interference and characteristics of spinal cord injury. Spinal Cord, 46(6), 451-5.
    Hans, G., Masquelier E., & De Cock, P. (2007). The diagnosis and management of neuropathic pain in daily practice in Belgium: an observational study. BMC Public Health, 7, 170. http://dx.doi.org/10.1186/1471-2458-7-170
    Budh, C.N., et al. (2003). Pain in a Swedish spinal cord injury population. Clinical Rehabilitation, 17(6), 685-690. http://dx.doi.org/10.1191/0269215503cr664oa
    Siddall, P.J., et al. (2003). A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury. Pain, 103(3), 249-257. http://dx.doi.org/10.1016/S0304-3959%2802%2900452-9
    Bennett, M. (2001). The LANSS Pain Scale: The Leeds assessment of neuropathic symptoms and signs. Pain, 92(1-2), 147-57. http://dx.doi.org/10.1016/S0304-3959(00)00482-6
    Finnerup, N.B., et al. (2001). Pain and dysesthesia in patients with spinal cord injury: A postal survey. Spinal Cord, 39(5), 256-62. http://dx.doi.org/10.1038/sj.sc.3101161