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CSRO
MAGAZINE BACK ISSUES
Pain
in Spinal Cord Injury
By: Wise Young, M.D. Ph.D.
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Pain is very common after spinal cord injury. Several systematic
surveys (mostly from Europe, particularly Scandinavia) and a few
limited studies in the United States have reported that as many as
50% of all people with a spinal cord injury suffer from pain developing
after the injury. Estimates of severe or disabling pain that is not
adequately relieved by therapy range from 10 to 25% of the spinal
cord injured population. Since most people equate spinal cord injury
with loss of sensation and paralysis, the problem of pain and abnormal
sensations was not adequately recognized or studied until fairly
recently.
The following are four types of pain in spinal cord injury:
1. Musculoskeletal Pain. These are pains that can be localized
to specific sites associated with identifiable muscle, ligament,
or bony abnormalities. These include pain at the spinal fracture
site, instrumentation (Harrington rods, etc.), resulting from stress
and strain placed on remaining joints and ligaments by an injury.
The spinal column normally distributes movement over many joints.
Fixation of one or more spinal segments results in greater stress
of remaining non-fixed segments. Also, due to paralysis, remaining
muscles tend to move some joints more than others and thereby contributes
additional stress on the operating joints. These occur in both paraplegics
and quadriplegics. In paraplegics, especially those who are walking,
hip and lower back pain is common. With quadriplegics, neck and arm
pain is common. There is often tenderness at the involved site. Treatment
for musculoskeletal pains differ from person to person. An effective
solution requires common sense and must include non-medical approaches.
Prevention is the best cure, e.g. avoidance of too much spinal fixation,
careful design of exercise that do not overstress bones and joints,
adjusting your wheelchair and environment to reduce musculoskeletal
stress when getting around, eschewing activities that may place too
much stress on specific joints, etc. Musculoskeletal pains are often
responsive to anti-flammatory drugs such as aspirin, acetaminophen
(Tylenol), and other mild analgesics. It is important to point out
that musculoskeletal pain and the consequent behavioral adaptations
to that pain (i.e. not using a painful joint or a change in posture)
often leads to more stress and strain of remaining joints, ligaments,
and muscles, and therefore more pain. Part of the aim of therapy
is to break the cycle of pain.
2. Visceral Pain and Pressure Sores. People with spinal cord
injuries have a high risk for problems of the bowel, bladder, kidney,
gallbladder, stomach, and other deep organs. Kidney stones, for example,
are common. Likewise, bladder infections occur regularly in a large
majority of people with a spinal cord injury. Diagnosis of such problems
are often complicated because the presentation of symptoms do not
follow typical patterns. The pain is often referred to another place
of the body. For example, gall bladder pain can appear to be localized
in the right shoulder. Pressure sores or decubiti also can contribute
to pain, although often not at the site of the skin breakdown. Visceral
pain is often associated with sweats, blood pressure changes, and
increased spasticity. The medical approach is of course to identify
such causes of pain and eliminate them.
3. Proximal Neuropathic Pain. These are pains that are localized
close to and appear to be emanating from the injury site. These pains
differ in quality, intensity, and location, often shifting from day
to day, from morning to evening, and even every few days but are
not affected by posture and other activities. The sensations are
unusual. I have heard people characterize them as 'burning', 'pressure',
'buzzing', or even 'freezing'. The pain sometimes appears to be deep
and this requires investigation to rule out potential problems such
as kidney stones, gallstones, liver pain, stomach and duodenal ulcers,
bowel disease, etc. The pain may be associated with constipation
and altered urinary flow, although it is not clear what the cause
is and what is affected. Because these sensations differ from what
many people associate with garden-variety pain, many people do not
describe these sensations as 'pain'. Nevertheless, they can be very
intense and can have great discomfort. These sensations are often
mixed in with musculoskeletal and visceral pain, decubiti, spasticity,
etc. Pain may develop late, many years after injury, and is sometimes
associated with the appearance and extension of the post traumatic
syrinx, a cystic cavity in the spinal cord that may span many segments.
The medical approach is to rule out and correct musculoskeletal,
gastraoinstinal, renal, spinal syringomelia, and other causes. If
nothing shows up or corrections of such problems do not relieve the
problem, trials of mild analgesics, tricyclic antidepressants, anti-spasticity
medication such as baclofen (lioresal) and gabapentin (nerontin),
and opiates are started. There has been one recent report that a
drug call 4-Aminopyridine (not yet approved by the FDA) may reduce
such pains in people (see below for more therapies). However, there
is generally no accepted or proven therapy.
4. Distal Neuropathic Pain. This is a common variant of neuropathic
pain. Instead of being close to the injury site, such pain can emanate
downward, often into the legs, down to the heels. The pain can involve
a single side, even a single toe. Again, the quality, intensity and
distribution of abnormal sensations can vary enormously, ranging
from tingling to severe pain. They can be constant, occur intermittently,
or come in herds. These sensations can be mixed in with skeletal
and visceral pain, or associated with decubiti, spasticity and bladder
infections. Some people ease their pain to sitting on a hot-plate.
Others describe vibratory sensations. People have evolved all sorts
of behaviors to avoid aggravating the pain or to reduce the pain,
e.g. sleeping in unusual positions. One unusual characteristic of
distal neuropathic pain is that it can occur in parts of the body
that are bereft of all other sensations. Like proximal neuropathic
pain, the medical approach is to rule out treatable causes and then
trials of analgesics, antidepressants, and anti-spasticity medication.
A number of centers have reported that intrathecal baclofen (given
through a catheter directly to the spinal cord) effectively blunts
neuropathic pain in some people. There are some preliminary reports
that a calcium channel blocker called SNX-111 may reduce certain
forms of pain when given intrathecally; this drug is undergoing clinical
trials at present but, to my knowledge not in people with spinal
cord injuries. A general concept of neuropathic pain is beginning
to emerge: Neuropathic pain emanated from the nervous system and
may well be the sensory counter-part to spasticity. In the same way
spasticity occurs in parts of the body that have lost motor connections,
neuropathic pains occurs in parts of the body that have lost their
sensory input. Neuropathic pain often responds to antispasticity
therapy. There is also a strong feeling among physicians who take
care of pain problems that neuropathic pain resulting from a spinal
cord injury share mechanisms with the 'phantom' pain that many amputees
suffer. In general, systemic or oral opiate medications are not effective
other than blunting pain perceptions, although there have been reports
that intrathecal morphine have helped some people. Incidentally,
when anti-depressants work, it does not necessarily mean that depression
is the cause of the pain. Rather, anti-depressants may be working
by manipulation of neurotransmitter levels in the central nervous
system. Although psychological factors play an important role in
the perception of pain, it is clear that neuropathic pain is not
imagined. Recent animal studies suggest that some forms of neuropathic
pain are associated with abnormal low levels of the inhibitory neurotransmitter
GABA, in the spinal cord below the injury site. Until recently, there
were no good animal models of neuropathic pain. It was quite difficult
to do animal pain research, for obvious reasons, since researchers
are bound by legal and ethical rules to avoid causing pain and suffering
in experimental animals. However, recent work suggest that reduction
of sensory input from a peripheral nerve can cause a condition called
allodynia (increased response to light touch) and that this condition
may be responsive to therapies that reduce neuropathic pain. There
is a considerable interest in the use of electrical stimulation of
the spinal cord or peripheral nerves to reduce neuropathic pain.
Here are some suggestions for people desperate for pain relief. One
is called dorsal root rhizotomy, where the sensory roots to the spinal
cord are cut or lesioned electrically or with lasers. A second approach
is to shunt the post-traumatic cavity (syringomyelia) in the spinal
cord, especially if it seems to be expanding. Another third approach
is to hemisect or transect the spinal cord below the injury site,
assuming that no recovery will occur anyway. There may even be suggestions
to destroy some pain centers in the brain, to reduce perception of
the pain. It is important to remember that such surgical procedures
are not always effective for pain reduction and pain frequently can
recur. Since lesions of the brain or spinal cord cannot be easily
reversed, great care and consideration should go into decisions for
such treatments.
I would strongly recommend getting opinions from multiple doctors
before undergoing surgical procedures for relief of neuropathic pain.
It is important to keep in mind that more and better research is
going on. For example, the National Center of Medical Rehabilitation
and Research at NIH initiated a major new program to study spinal
cord amputation pain. New information and therapies will undoubtedly
emerge in the next few years, providing better and more effective
options, circumventing the need for drastic surgical procedures.
The subject of pain in a spinal cord injury is complex and difficult
to summarize. I don't know much about chiropractic, acupuncture,
hypnosis, and psychological treatments of pain and therefore omitted
these approaches. I further emphasize that the above is mostly personal
opinion and not a substitute for medical advice.
The
Road to Fitness
Article written by:
Juli Fiorini
Sandra Mills
Darryl Tracy |
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Well, Spring is coming and it's time to get in shape. I know everyone
is thinking about it, so lets go through what can be done about trimming
those extra pounds off your body through fitness and well-being.
The first step in a physical fitness program should be a complete
physical examination and approval of the proposed program by a physician.
In beginning an exercise program you should keep the periods short
and not excessively strenuous. Gradually, however, the exercise periods
can be lengthened and involve more exertion.
Basic traits of physical fitness include strengthening and endurance.
Strengthening muscles is important for physical activities such as
transfers, wheeling and daily living activities. An excellent way
of improving certain muscle group strength is wheeling. Muscular
imbalances can be created in and around the shoulder and upper back,
so please be sure to always have a complimentary training program.
A fitness program should be done on a regular basis to achieve success,
at least three times a week. When starting an exercise program, progress
slowly, have a well-rounded exercise routine, consisting of controlled
movements and rests in between sets.
To improve your level of endurance, cardiovascular exercise is essential.
To achieve cardiovascular benefits, exercise must be of a moderate
level of intensity, duration and frequency, to create a higher level
of endurance. Using an exercise scale of 1-10, with 1 being easy
and 10 being extremely difficult, you should be working in the 6-8
range. You should feel as though you are working hard in order to
achieve training benefits.
Here are the benefits of regular exercise:
- Improve self image and outlook on life
- More restful sleep
- Less desired consumption of drugs, coffee, tea, alcohol, sugar
and refined carbohydrates
- Lessening of nervous tension
Use the natural environment, parks, forests, beaches and hills, as
much as possible.
So now your motivated, then what? Regular exercise is sometimes difficult
to maintain if you don't have the facilities to accommodate you.
Lyndhurst Hospital - The Spinal Cord Centre in Toronto, has just
opened its very own fitness facility, Lyndhurst Fitness Centre. This
facility is open evenings and gives people an opportunity to develop
new relationships, learn or practice recreational skills and of course
start on the journey towards physical fitness.
Lyndhurst - The Spinal Cord Centre has recognized for a number of
years that there is a lack of facilities that can be used by people
with Spinal Cord Injuries (S.C.I.) to maintain or improve their level
of fitness. For a number of years both consumers and Therapy staff
at Lyndhurst have realized that many fitness facilities open to the
general public are not adequately accessible to this population,
nor do they provide equipment that can be adapted for the wheelchair
user.
With this in mind, the Lyndhurst Fitness Centre has taken this opportunity
and created a facility to allow individuals to maintain or improve
their current level of physical fitness. The following benefits can
be achieved:
- Provide an accessible environment for the recreation and fitness
needs of the SCI community.
- Maximize use of available resources and potentially expand
resources (i.e. equipment) through donations/sponsors/advertisers.
- Expand Lyndhurst's role in meeting the physical and social
needs of the SCI community.
- Maximize Lyndhurst's reputation as a provincial resource for
fitness training and equipment needs for persons with a physical
disability.
- Promote personal independence and responsibility.
- Facilitate an improvement in the physical health of an individual,
such as: improved weight control and strength; decreased body
fat; improve circulation and vital capacity; increase endurance.
The Lyndhurst Fitness Centre is for people living in the community
who have a spinal cord injury or related neurological condition.
The equipment at the centre include: Arm Bike; Leg Bike; Stationary
Bike; Wall Pulleys; Uppertone Gym; Versatrainer; Access Trainer;
Treadmill; Wheelchair Roller; Free Weights; Theraband; Mats for Stretching;
Quads Bench.
Lyndhurst Fitness Centre is staffed by a Fitness Appraiser, Aide,
Clerical Assistant and a Recreation Therapist.
New members to the Fitness Centre will participate in a fitness appraisal
followed by the development of a personalized fitness program. This
program will be specifically designed by qualified staff, to meet
the identified fitness and wellness goals of the member. Various
lifestyle programs will also be available to the members to round
out their fitness program. Members can participate in activities
such as aerobics, tai chi, stress management, nutrition and lifestyle
counseling, as well as join wheelchair basketball and rugby houseleagues.
If you live in the Toronto area and would like to become involved
with the Lyndhurst Fitness Centre please contact Sandra Mills (ext.
1281) or Darryl Tracy (ext. 1271) at Lyndhurst The Spinal Cord Centre
at (416) 422-5551
On January 28th, Jamie Hunter presented Eric Carleton of KLM Royal
Dutch Airlines, with an acknowledgment for their generous ongoing
support. KLM has donated office equipment which has increased the
efficiency of our office. KLM Royal Dutch Airlines fly Internationally
and have an excellent reputation for accommodating disabled persons.
We thank you again.
Board
Member Profile
Gary Reinblatt
"I could have made millions of dollars betting
the doctors on my recovery." |
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Gary Reinblatt has been a member on the CSRO Board of Directors since
1992. Gary is presently President of Reinblatt Group Associates,
a marketing consulting firm that deals with clients in manufacturing,
media, sales promotion and advertising agencies. With 25 years experience
at McDonald's Restaurants as Senior Vice President and National Director
of Marketing , Gary brings his knowledge and experience to the board.
Presently, Gary serves on the Board of North York General Hospital,
Ronald McDonald Children's Charities, and Think First Canada. In
March of 1990, Gary had a skiing accident which rendered him a quadriplegic.
Since then he has made a great recovery and has partial use of all
parts of his body. Gary is a great asset to our organization and
we would like to thank him for sharing his expertise and assisting
us with various marketing projects.
Womens
Fundraising Committee Member Profile
Melanie Munk |
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Melanie has been an active member of our Women's Fundraising Committee
since 1991/92, being involved in several events such as "Only You", "Miss
Saigon" , "Tru" and is one of the sponsors for the reception for
the upcoming "Fiddler on the Roof" event taking place in April (1997).
"I first became involved with the Canadian Spinal Research Organization because
of my friendship with Wendy Crawford-Burton, who I met at a Red Cross fundraising
event in 1990. We became friends and have remained so ever since. I was proud
of her fashion venture, and greatly admire her spirit, her courage and her enthusiasm
for life - all of which remain undiminished in spite of enormous difficulties.
"It's a real tragedy that spinal injuries are so often sustained by young people
- people in their prime and with their whole lives before them. I firmly believe
that a cure is a reality, and that this will be achieved through the work of
the CSRO and the efforts of outstanding people like Wendy Crawford-Burton and
Christopher Reeve.
We would like to take this opportunity to thank Melanie for all the
wonderful support she continues to give by her leadership with the
Women's Fundraising Committee and through her generous financial
and personal efforts.
CSRO
celebrates the
25th Anniversary of "Fiddler on the Roof"
with Norman Jewison... |
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Norman and Dixie Jewison have been long-time supporters of the search
for a cure for paralysis due to spinal cord injury. This dedicated
couple have been partners with the CSRO since 1993 as members of
the Board of Directors and sponsors of many exciting and successful
fundraising events. This year, CSRO is honoured to be presenting
Norman Jewison’s "Fiddler on the Roof" on its 25th Anniversary.
The star of the original film, Topol, and his family will also join
in our celebration of this family classic.
In the film, Topol is Tevye, a poor Jewish milkman with five unmarried
daughters to support in the village of Anatevka in Czarist Russia.
With a sharp-tongued wife at home and growing anti-Semitism in the
village, Tevye talks to God about his troubles. His people’s
traditions keeps Tevye strong when his existence is balanced precariously
as a fiddler on the roof.
Thank you for all who attended and thank you Norman & Dixie for your
continued support.
There’s
more to your membership than you know....
Ask your local Speedy Muffler King. |
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Speedy Muffler King would like to invite CSRO Members to join the
Speedy Club, at no extra cost, to bring in their car, van, or light
truck to any one of their over 150 convenient locations across Canada.
Just mention that you are a CSRO member, family or friend of a member,
and you will receive a 15% discount on all Speedy’s regular
services. A 10% discount will be applied to their everyday low price
on tires (40% off Michelin and 35% off BFGoodrich).
The offer to Speedy Club members applies to:
Complete brake service
Oil, lube and filter service
Tires and Wheel Alignment
Complete exhaust system repair
Suspension service, shock, struts, and coil springs.
Front End Drive
Maintenance Packages
A percentage of all discounts received by CSRO Members will be donated
back to CSRO by Speedy Muffler.
So, hurry to Speedy Muffler and get a great deal on car repairs while
supporting CSRO at the same time!
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