7. Management of Musculoskeletal Pain

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

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

The Problem:

Musculoskeletal pain is reported by 40-65% 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.

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, 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:

    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 Medicine34(3): 278-84.

Additional references:

    Barrett, H., et al. (2003). Pain characteristics in patients admitted to hospital with complications after spinal cord injury. Archives of Physical Medicine & Rehabilitation84(6): 789-95. http://dx.doi.org/10.1016/S0003-9993(02)04944-4
    Budh, C.N., & Lundeberg, T. (2004). Non-pharmacological pain-relieving therapies in individuals with spinal cord injury: a patient perspective. Complementary Therapies in Medicine12(4): 189-197. http://www.sciencedirect.com/science?_ob=ArticleURL…
    Cardenas, D.D., & Jensen, M.P. (2006). Treatments for chronic pain in persons with spinal cord injury: A survey study. Journal of Spinal Cord Medicine29(2): 109-117.
    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 Medicine28(5): 434-70. http://www.pva.org/site/News2?page=NewsArticle&id=7641
    Curtis, K.A., et al. (1999). Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users. Spinal Cord37(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 Cord37(3): 191-5. http://dx.doi.org/10.1038/sj.sc.3100802
    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): p. 578-585. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607131/?report=abstract
    Guzman, J., et al. (2001). Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ322(7301): 1511-6. http://dx.doi.org/10.1136/bmj.322.7301.1511
    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 Rehabilitation2(10): 896-900.
    Koontz, A.M., et al. (2006). Investigation of the performance of an ergonomic handrim as a pain-relieving intervention for manual wheelchair users. Assistive Technology18(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.
    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. Pain80(1-2): 1-13.
    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 & Rehabilitation88(1): 70-75. http://dx.doi.org/10.1016/j.apmr.2006.10.003
    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