7. Management of Musculoskeletal Pain

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

The Problem:Man using hand to brake wheelchair

Musculoskeletal pain is reported by 40-85% of people with spinal cord injuries, most frequently located in the back, neck and upper extremity. Musculoskeletal pain may arise from soft tissue injury, bone or joint injury, nerve root entrapment, overuse syndromes, spasms, or cognitive-affective issues. Common pain syndromes include rotator cuff injury and carpal tunnel syndrome, both related to repetitive over-use of the upper limbs for wheelchair mobility, transfers and self-care. Upper extremity pain has extreme consequences for independence, social participation and quality of life.

Actionable Nugget

Chronic musculoskeletal pain requires an interdisciplinary approach, including rehabilitation, and in some cases, surgery.

Evidence-based Best Practice:

Acute and sub-acute musculoskeletal pain should be treated as it would be in the general population. Treatment approaches for musculoskeletal pain with evidence of effectiveness in SCI include: analgesic pharmacotherapy, physiotherapy, massage, exercise and cognitive-behavioral therapy.

For chronic musculoskeletal pain, additional considerations include wheelchair modifications and other assistive devices to relieve pain and prevent further damage. A power wheelchair should be considered for those whose functional mobility in a manual wheelchair is impeded by pain. Interdisciplinary approaches to pain management have been shown to improve function and reduce pain. Corrective surgery may be beneficial, if potential functional gains outweigh losses associated with recovery time.

Key reference:

    Michailidou, C., Marston, L., De Souza, L. H., & Sutherland, I. (2014). A systematic review of the prevalence of musculoskeletal pain, back and low back pain in people with spinal cord injury. Disability and Rehabilitation, 36(9), 705-715. http://doi.org/10.3109/09638288.2013.808708

Additional References (chronological listing):

    Eriks-Hoogland, I., de Groot, S., Snoek, G., Stucki, G., Post, M., & Van der Woude, L. (2016). Association of Shoulder Problems in Persons With Spinal Cord Injury at Discharge From Inpatient Rehabilitation With Activities and Participation 5 Years Later. Archives of Physical Medicine and Rehabilitation, 97(1), 84-91. http://doi.org/10.1016/j.apmr.2015.08.432
    Eriks-Hoogland, I. E., Hoekstra, T., de Groot, S., Stucki, G., Post, M. W., & van der Woude, L. H. (2014). Trajectories of musculoskeletal shoulder pain after spinal cord injury: Identification and predictors. The Journal of Spinal Cord Medicine, 37(3), 288–98. http://doi.org/10.1179/2045772313Y.0000000168
    Alves, AP; Terrabuio, AA; Pimenta, CJ; Medina, GIS; Rimkus, CM; Cliquet, A. (2012). Clinical Assessment and Magnetic Resonance Imaging of the Shoulder of Patients With Spinal Cord Injury. Acta Ortop Bras, 20(5), 291–296.
    Kemp, B.J., Bateham, A.L., Milroy, S.J., Thompson, L., Adkins, R.H., & Kahan, J.S. (2011). Effects of reduction in shoulder pain on quality of life and community activities among people living long-term with SCI paraplegia: A randomized control trial. Journal of Spinal Cord Medicine, 34(3), 278-84.
    Jain, N.B., Higgins, L.D., Katz, J.N. & Garshick, E. (2010). Association of shoulder pain with the use of mobility devices in persons with chronic spinal cord injury. Physical Medicine and Rehabilitation, 2(10), 896-900.
    Dieruf, K., L. Ewer, & Boninger, D. (2008). The natural-fit handrim: factors related to improvement in symptoms and function in wheelchair users. Journal of Spinal Cord Medicine, 31(5), 578-585. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607131/?report=abstract
    Nash, M.S., van Elk, N., & Johnson, B.M. (2007). Effects of circuit resistance training on fitness attributes and upper-extremity pain in middle-aged men with paraplegia. Archives of Physical Medicine & Rehabilitation, 88(1), 70-75. http://dx.doi.org/10.1016/j.apmr.2006.10.003
    Cardenas, D.D., & Jensen, M.P. (2006). Treatments for chronic pain in persons with spinal cord injury: A survey study. Journal of Spinal Cord Medicine, 29(2), 109-117. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1864800/?report=abstract
    Koontz, A.M., et al. (2006). Investigation of the performance of an ergonomic handrim as a pain-relieving intervention for manual wheelchair users. Assistive Technology, 18(2), 123-43; quiz 145. http://www.resna.org/content/index.php?pid=269
    McCasland, L.D., et al. (2006). Shoulder pain in the traumatically injured spinal cord patient: evaluation of risk factors and function. Journal of Clinical Rheumatology, 12(4), 179-86. http://dx.doi.org/10.1097/01.rhu.0000230532.54403.25
    Nawoczenski, D.A., et al. (2006). Clinical trial of exercise for shoulder pain in chronic spinal injury. Physical Therapy, 86(12), 1604-18. http://dx.doi.org/10.2522/ptj.20060001
    Consortium for Spinal Cord Medicine (2005). Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals. Journal of Spinal Cord Medicine, 28(5), 434-70. http://www.pva.org/site/News2?page=NewsArticle&id=7641
    Budh, C.N., & Lundeberg, T. (2004). Non-pharmacological pain-relieving therapies in individuals with spinal cord injury: a patient perspective. Complementary Therapies in Medicine, 12(4), 189-197. http://www.sciencedirect.com/science?_ob=ArticleURL…
    Barrett, H., et al. (2003). Pain characteristics in patients admitted to hospital with complications after spinal cord injury. Archives of Physical Medicine & Rehabilitation, 84(6), 789-95. http://dx.doi.org/10.1016/S0003-9993(02)04944-4
    Guzman, J., et al. (2001). Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ, 322(7301), 1511-6. http://dx.doi.org/10.1136/bmj.322.7301.1511
    Curtis, K.A., et al. (1999). Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users. Spinal Cord, 37(6), 421-9. http://dx.doi.org/10.1038/sj.sc.3100860
    Dalyan, M., Cardenas, D.D., & Gerard, B. (1999). Upper extremity pain after spinal cord injury. Spinal Cord, 37(3), 191-5. http://dx.doi.org/10.1038/sj.sc.3100802
    Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80(1-2), 1-13. http://dx.doi.org/10.1016/S0304-3959(98)00255-3