5. Assessment of Pain in SCI Patients

Actionable Nuggets for SCI (2nd ed., 2013)

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 nine different types of pain may occur alone or in combination, even at the same location. SCI pain can be broadly classified as either neuropathic (central origin) or musculoskeletal (peripheral origin). 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 84% sensitivity and 92% specificity (see attached).

Key reference:

    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 Medicine29(5): 578-85.

Additional references:

   Bennett, M. (2001). The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain,92(1-2): p. 147-57. http://dx.doi.org/10.1016/S0304-3959(00)00482-6
    Budh, C.N., et al. (2003). Pain in a Swedish spinal cord injury population. Clinical Rehabilitation17(6): 685-690. http://dx.doi.org/10.1191/0269215503cr664oa
    Cardenas, D. D., & Felix, E. R. (2009). Pain after Spinal Cord Injury: A Review of Classification, Treatment Approaches, and Treatment Assessment. Physical Medicine and Rehabilitation1(12): 1077-1090.
    Celik, E.C., Erhan, B., & Lakse, E. (2012). The clinical characteristics of neuropathic pain in patients with spinal cord injury. Spinal Cord50: 585-89.
    Cruz-Almeida, Y., Felix, E. R., Martinez-Arizala, A., & Widerstrom-Noga, E. G. (2009). Pain symptom profiles in persons with spinal cord injury. Pain Medicine10(7): 1246-1259.
    De Miguel, M., & Kraychete, D. C. (2009). Pain in patients with spinal cord injury: A review. [Portuguese, English]. 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 & Development46(1): 13-29.
    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 & Development46(1): 69-83.
    Finnerup, N.B., et al. (2001). Pain and dysesthesia in patients with spinal cord injury: A postal survey. Spinal Cord39(5): 256-62. http://dx.doi.org/10.1038/sj.sc.3101161
    Finnerup, N.B., et al. (2008). Abdominal pain in long-term spinal cord injury. Spinal Cord46(3): 198-203. http://dx.doi.org/10.1038/sj.sc.3102097
    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 Neurotrauma28: 1445-47.
    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 Medicine52(2):173-9.
    Haanpaa, M. (2011). Are neuropathic pain screening tools useful for patients with spinal cord injury? Pain152(2011): 715-16.
    Hallstrom, H., & Norrbrink, C. (2011). Screening tools for neuropathic pain: Can they be of use in individuals with spinal cord injury? Pain152(2011): 772-79.
    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 Health7: 170.
    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 & Rehabilitation92(1): 146-160.
    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 Cord48(3): 230-8.
    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 Medicine52(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 Medicine52(2): 173-179.
    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 Medicine11(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 Rehabilitation32(2): 114-24.
    Sawatzky, B., et al. (2008). Classification and measurement of pain in the spinal cord-injured population. Spinal Cord46(1): 2-10. http://dx.doi.org/10.1038/sj.sc.3102137
    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.
    Ullrich, P.M., Jensen, M.P. Loeser J.D., & Cardenas, D.D. (2008). Pain intensity, pain interference and characteristics of spinal cord injury. Spinal Cord46(6): 451-5.
    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 & Development46(1): 43-56.