Pain Management

Many individuals feel some type of pain after a catastrophic injury. Severe pain is a problem for about one in three people with major injuries. Pain can interfere with your ability to carry out your daily routines, social activities, and greatly affect your quality of life.

Effective pain management helps improve quality of life, daily functioning and long-term pain resolution.

Understanding Pain After Injury

There are numerous causes of pain some examples are broken bones, injured joints and muscles or damaged nerves. Movement of muscles and joints after long periods of non-use can also cause pain.

In persons with spinal cord injury (SCI) or brain injury (BI), there may also be changes in the way the body feels pain because of changes in the nervous system. Some persons with SCI or BI feel pain in places where they have abnormal or even absent sensation or feeling.

Pain Is a Symptom, Not a Diagnosis

Pain is not a diagnosis; rather it is a symptom. Being a symptom, it may be a sign that something is wrong, but other times it may be a normal response to changes in the body.

Pain may be present from the onset of injury or may slowly develop over time. Your health care team can help you figure out what is causing your pain and, more importantly, what can be done to treat it. Effective pain management and treatment plans are based on identifying the cause of pain and selecting appropriate pain control methods.

Causes of Pain and What Makes Pain Worse

Certain conditions may make your pain worse, including numerous medical issues such as infection, bladder, bowel, or skin problems, as well as other factors such as over-exertion, physical or emotional fatigue, frustration, changes in weather, or even smoking.

You may not tell anyone about your pain or the things that make it worse, for fear others will think you are “crazy” or “weak”. Discussing your pain with the team can help determine if it’s a signal that something is wrong, or if it’s a “normal” symptom. Communicating with your team is the first step toward understanding the causes of pain and different treatment options.

Your Rights and Responsibilities in Pain Management

You Have a Right to Pain Management

As a patient at Craig Hospital, you can expect:

• Your treatment team will take your reports of pain seriously.
• Information about pain and ways to help with your pain will be provided.
• A concerned staff committed to pain prevention and management.
• Health care professionals who respond to reports of pain.

Your Responsibilities in Pain Management

As a patient in this hospital, we expect that you will:

• Ask your health care team what to expect about pain and pain management.
• Discuss pain relief options with your health care team.
• Work with your health care team to develop a pain management plan.
• Help your health care team assess your pain.
• Tell your health care team when the pain is not relieved.
• Always talk with your doctor, nurse or pharmacist about any worries you may have about taking pain medication.

Why Pain Management Is Important

Pain can cause the following signs and symptoms:

• Tiredness
• Depression
• Anger
• Worry
• Loneliness
• Stress
• Poor Appetite
• Increased alcohol and/ or drug use

Pain can interfere with the following:

• Daily activities
• Interest in work and hobbies
• Sleeping
• Sexual activity
• Eating
• Spending time with friends and family
• Enjoying life
• Working on your rehab goals

Tell Your Care Team About Your Pain

• Where do you feel pain?
• What does it feel like (sharp, dull, burning, electrical)?
• How long have you had the pain?
• What do you do to make it better?
• What makes it worse?
• What medications or treatments are helpful? What medications or treatments have not been helpful?

Types of Pain

The two types of pain are: acute and chronic pain.

Acute Pain

Acute pain typically begins suddenly. The cause of the pain is usually from physical damage to the body or from a disease process. Acute pain is a danger signal and you should discuss it with your team to be sure it is evaluated properly.

Remember that your body’s ability to report pain needs to be addressed. Acute pain usually gets better with or without intervention, but may take several months to completely be resolved.

Chronic Pain

When pain does not go away, and lasts longer than several weeks to months, it is usually considered to be chronic. However, this does not mean that there is no hope for improvement.

There can be many causes of chronic pain in SCI and BI, and there are many different treatment strategies that your team can offer.  Chronic pain is difficult to completely eliminate, but often significant reduction in the pain is possible. While chronic pain is usually not dangerous, it is important that you notify your team if your chronic pain suddenly worsens.

Types of Pain After Spinal Cord or Brain Injury

There are several types of pain commonly felt by individuals with SCI or BI. Some types of pain involve mechanisms that might cause any person to have pain. Other types of pain involve mechanisms that are typically only found in people who have had an injury to the brain, spinal cord or other parts of the nervous system. Your team can help you understand these different types of pain and what can be done about them.

Mechanical Pain

Mechanical pain usually involves areas of normal sensation but not necessarily areas of normal function. This type of pain can occur suddenly or have a delayed onset. Symptoms can range from dull to sharp or achy to throbbing. It usually involves a physical cause, such as injury to muscle, joint or bone. This type of pain can happen to anyone. Spasticity is also a common cause of mechanical pain. This is a condition in which muscles have difficulty relaxing due to SCI or BI.

Referred Pain

Referred pain can occur in persons with or without nervous system injury and it can be a common source of pain especially in SCI. One example is when a person has a heart attack, they may have jaw numbness or pain in their left shoulder or arm.

In SCI, referred pain may indicate that an area below your level of normal sensation is having a problem. One common example in SCI includes shoulder pain as a result of gallbladder disease. Referred pain can also happen in BI but is less common.

Central Deafferent Pain

In persons with SCI, central deafferent pain can be quite perplexing. You feel pain where you have abnormal or even absent sensation. Common descriptions include a “pins and needles” feeling, electrical, burning, numbness, or shooting pain below your level of injury. The pain may not develop for weeks or months, if at all. It may also fluctuate or change. It may be constant and may change with physical activity. At best, it is bothersome. At worst, it may limit your ability to fully function in life.

Doctors believe the cause of central deafferent pain may be changes in the functioning of spinal nerves following SCI. This type of pain is not typically a sign that the injury is getting worse. People with a BI sometimes can experience a similar pain syndrome, though the cause is related to injuries of the brain instead of the spinal nerves. People with this type of pain may be very sensitive to light touch or other stimulation that might not be ordinarily considered painful.

Root Pain

Root pain (also known as junctional pain) refers to the distinct pattern of pain associated with SCI. This type of pain is felt at or just below the level of injury. It may begin days to weeks after injury and may feel like sharp or burning pain near the area where your normal feeling stops. This type of pain is similar to central deafferent pain in that physical activity may not affect it, and the area(s) involved may be overly sensitive to touch, also known as hypersensitivity. It is believed that damage to the nerve roots at the level of injury causes this type of pain. This type of pain does not indicate worsening of the injury.

Cyst (Syrinx) Pain

When the spinal cord is injured, a fluid-filled cavity can form within the spinal cord itself, called a cyst or syrinx. Cysts can be very serious. The cyst can sometimes expand up or down the spinal cord. A cyst can cause several different symptoms including sensory loss, weakness, and/or pain. Symptoms may not occur for months or years and may also develop very slowly. This condition is rare and occurs only in SCI. It is important to discuss all pain issues with your team.

Measuring Pain and Pain Intensity

Whether you have a brain injury or a spinal cord injury, we know that your pain is very real. Most people with spinal cord or brain injury are able to tell the doctors and nurses when they have pain and how bad it feels.

Family and staff members need to be very observant of someone who is not able to communicate on their own and watch for signs that may indicate pain. Changes in vital signs, such as increased heart rate, blood pressure or the rate of breathing may indicate that someone is in pain. Changes in behavior such as restlessness, moaning, grimacing, increased anxiety, irritability, or agitation may also be a response to increased pain.

A pain scale helps you rate pain intensity. At Craig Hospital, your nurses will ask you to rate your pain on a 0 to 10 scale. A rating of 0 means no pain, and 10 is the worst pain possible.

Rate the pain every few hours. You may feel pain even with medications or treatments. Tell your doctor or nurse if the pain is not reduced. Be sure to mention if the pain suddenly increases or changes.

Treatment of Pain After Injury

Pain treatments depend on the type of pain a person has. Pain treatment can vary from person to person and depend on their symptoms. While researchers continue to study pain, there is no single treatment that works best for everyone or for every situation.

Acute Pain Treatment

Acute pain usually responds well to treatment involving a combination of strategies, including medications, physical treatments, and counseling.

This type of pain is treated after you report it to your doctor.

Chronic Pain Treatment

Because chronic pain can be very difficult to treat, the multidisciplinary team approach is very important. It is unusual for a single strategy to effectively treat chronic pain. It is very important that you work with each member of your team.

Unfortunately, when pain becomes chronic, realistic goals typically involve reduction of pain and adaptation to pain, as opposed to complete elimination of pain. Your team may recommend some unusual medications and/or techniques, and it is important that you keep an open mind about different treatment strategies.

Methods of Treating Pain

Since pain can have many causes, there is no single way to treat it, whether it is acute or chronic. Because SCI and BI can also have specific types of pain syndromes not normally present in the general population, it is very important that your team works with you to provide information about your type(s) of pain.

Medications are just part of the solution. Your doctor, pharmacist and nurse can help explain the pros and cons of each one. Your therapists will also have strategies that do not involve medications but may be just as effective than any medication.

Psychologists or clergy are also important people in addressing your pain. Understanding your emotions and learning about different types of adaptation strategies are a critical part of your treatment. Your healthcare team can help you explore alternative options such as massage therapy and acupuncture.

Pain Medications

There are many different medications available to treat pain. Some are more familiar than others, and some may sound very unusual. All medications have potential side effects, some of which are more serious than others, and many medications may interact with each other. You need to tell your doctor as many specifics as possible so that he or she can choose the most appropriate medication(s) for you. All have shown some success in reducing pain, but again, none do so completely in every instance. Some of the side effects of these medications can be serious. Your doctor must closely watch your treatment.

It is important that you keep an open mind about medications. Many medications are used “off-label,” meaning that information you read from a drug manual or the internet may not be the only use of that medication. Your doctor is just as concerned about side effects as you are and will try to avoid medications that have many side effects or interactions with other medications.

It is very important that you take only what your doctor or nurse recommends, as additional medications, including herbal or over-the-counter (OTC), may have significant interactions with your prescription medications. You should discuss the use of herbal remedies with your doctor.

Non-Steroidal Anti-Inflammatory Drugs

Non-steroidal anti-inflammatory drugs, also known as NSAIDs, include aspirin, ibuprofen (Motrin, Advil), naproxen, Anaprox (Aleve), ketorolac (Toradol), indomethacin (Indocin), celecoxib (Celebrex), and rofecoxib (Vioxx).

NSAIDs have been used for many years with great success in treating various types of pain. They come in many forms, for example, pills, liquids, suppositories, and injections. Some are over-the-counter (OTC), and others are prescription only.

Common risks include stomach upset (including ulcers and bleeding), kidney problems, allergic reactions, and bleeding problems. They all have slightly different properties and potential side effects, and you should discuss with your doctor if this type of medication is safe for you.

Acetaminophen

Better known as Tylenol, acetaminophen (APAP) is also a very effective pain medication and typically has fewer side effects than most other medications. However, in very high doses (particularly over 4,000mg per day) it can cause liver damage and should never be mixed with alcohol.

It is commonly found in combination with other pain medications such as APAP/Oxycodone (Percocet) and APAP/Hydrocodone (Lortab).

Narcotics

Narcotics include combination medications such as APAP/codeine (Tylenol #3), APAP/hydrocodone (Lortab, Vicodin), APAP/oxycodone (Percocet), fentanyl (Duragesic), hydromorphone (Diluadid), meperidine (Demerol), methadone, morphine, and oxycodone.

This class of medications, also known as opioids, includes a large number of medications with varying degrees of pain relief, as well as variable side effects. They are commonly combined with acetaminophen (APAP) or NSAIDs.

Common side effects include confusion, fatigue, vomiting, itching, constipation, and bladder weakness (urinary retention). They can also cause lowered blood pressure and may diminish the body’s ability to breathe.

This class of medications always requires a prescription and may become habit forming. After long periods of use, your body’s response to narcotics may decrease; you may find that your pain continues to increase despite higher doses. However, side effects will worsen with increased dosages. You may also develop dependency on these medications, and abrupt discontinuation can cause withdrawal symptoms.

Narcotics are typically not effective for chronic pain but are usually very effective for acute pain. Dependency, or addiction, is very rare when narcotics are used properly. Your doctor can help you determine which, if any, of these medications might be helpful for you.

Muscle Relaxants / Anti-Spasticity Medications

Muscle relaxants include diazepam (Valium), baclofen (Lioresal), carisoprodol (Soma), cyclobenzapine (Flexeril), metaxalone (Skelaxin), methocarbamol (Robaxin), dantrolene (Dantrium), and tizanidine (Zanaflex).

These medications work by causing muscle relaxation. The medications work by either acting on the muscle or on the nerve input to the muscle.

Common side effects include sedation, dry mouth, confusion, low blood pressure, decreased breathing rate, and weakness.

Other Medication, Including “Off-label” Use

An “Off-Label” use is when a medication is prescribed for purposes other than originally approved by the Federal Drug Administration (FDA). Nevertheless, these medications can be safely prescribed by your doctor and may be very effective for pain, both acute and chronic, and particularly for pain syndromes that may occur after SCI or BI (but rarely in the general population). You should always discuss potential benefits, risks and side effects of these medications with your doctor.

These medications include:

• Tramadol (Ultram) does not fall into a specific category, and may be helpful in mild to moderate pain. Though it is not a narcotic, it carries a slight potential for dependency and should be used with caution if you are taking an antidepressant.
• Antidepressants, particularly tricyclic antidepressants such as amitriptyline (Elavil) or nortriptyline (Pamelor) and desipramine (Norpramin).
• Anxiolytics (also known as anti-anxiety medications), such as diazepam (Valium) and clonazepam (Klonopin), can also be effective muscle relaxants.
• Anticonvulsants (also known as anti-seizure medications) such as Neurontin are helpful for nerve pain associated with SCI. They are often used in combination with antidepressants.
• Antihypertensives (blood pressure medications) such as clonidine (Catapres), which is closely related to the muscle relaxant tizanidine (Zanaflex).

Alcohol is not a medication. Alcohol is not recommended as a pain medication and can lead to alcohol abuse and other serious problems. Some medications should not be mixed with alcohol. Check with your doctor if you have questions about drinking alcohol while on medication. It is important to always read the labels of your medications.

Potential Concerns About Medications

I’m afraid of becoming addicted.

Narcotic addiction is defined as dependence on the regular use of narcotics to satisfy physical, emotional, and psychological needs rather than for medical reasons. Pain relief is a medical reason for taking narcotics. If you and your doctor decide that narcotics are a proper choice for your pain relief, then use them as directed.

Fear of addiction is very common for people who take narcotics for pain relief. Narcotic addiction is a very emotionally charged subject. You may hear people use the term “addiction” very loosely without understanding that it means the compulsive use of habit-forming drugs for their pleasurable effects.

I don’t want to be a complainer.

You have the right to ask for pain relief. In fact, telling your doctor or nurse about pain is what all patients SHOULD do. The sooner they speak up, the better. It is easier to control pain in its early stages before it becomes severe.

I don’t want to lose control.

Most people do not lose control when they take pain medications the right way. You may feel sleepy when you first take some pain medications, but this feeling often goes away in a few days. Some people get dizzy or feel confused when taking pain medication. Tell your doctor or nurse if this happens to you. Changing your dose or type of medication usually helps solve this problem.

Other Pain Relief Options

Electrical Stimulation

Transcutaneous electrical nerve stimulation or “TENS” has provided relief from SCI pain in some individuals. This technique involves placing electrodes your skin and sending low levels of electrical current into your body. Doctors and physical therapists often use TENS first when addressing pain because the risks are low.

Another type of electrical stimulation is the dorsal column stimulator, also called an epidural stimulator. This is implanted under the skin and has proven helpful in some cases. It is a surgical procedure and is reversible.

Nerve Blocks and Surgery

Nerve blocks involve injecting a drug directly into the skin or spine. This method has fewer side effects than narcotics and the pain relief lasts longer. Doctors often use these treatments before neurosurgery because the risks are lower.

Dorsal root entry zones (DREZ)

DREZ is a neurosurgical procedure used to reduce pain in some people. A DREZ procedure involves heating parts of the spinal cord or nerve roots thought to be the source of pain.

Stretching and Range of Motion Exercises

Stretching and range of motion exercises that help release muscle tension may also help relieve pain. Applying ice or heat to the affected area may help reduce swelling and pain.

Therapeutic Massage

Therapeutic massage by a certified massage therapist (CMT) may also help in relieve pain caused by muscle tightness. Speak with your doctor if you are interested in massage therapy.

Acupuncture

Pain specialists have used acupuncture to treat chronic pain. Acupuncture treatment consists of the insertion of tiny needles into the skin at specific points. According to some experts, acupuncture works by stimulating the body’s pain control system or by blocking the flow of pain.

Psychological Treatment for Pain

While medical and surgical procedures for managing chronic pain are important, psychological approaches to coping with pain are equally important. Psychological approaches teach you coping and adaptation strategies. Don’t overlook or feel threatened by psychological support. Living with pain day after day will affect anyone’s view of themselves and the world. Working with a psychologist can help you understand this.

Other Pain Factors

Factors that can aggravate pain include depression and stress.

Depression

Depression can accompany pain or occur as a result of everyday living problems or coping with a spinal cord injury. Depression can magnify the pain experience and result in social isolation. Depression is best treated through counseling, either with professionals or peer counselors. Severe depression requires medication or other treatment. Successful treatment of depression can improve your ability to cope with chronic pain.

Stress

Stress is another factor that can magnify pain. You can learn to manage stress more effectively through counseling, either individually or with a group. Psychologists can teach you techniques to help you reduce stress and tension, such as relaxation training, biofeedback, and hypnosis.

Distraction is one of the best methods for coping with chronic pain. Keeping busy in enjoyable and meaningful activities, whether recreation, work or volunteer activities, is important. Inactivity and boredom may cause you to focus more on your pain.

How you think about your pain may affect how you cope and deal with it. If you believe it is a sign that something is terribly wrong with your body, you may avoid certain activities or rely on medications.

Pain is an invisible disability. Family members and friends may not understand your pain. They may become overprotective and resent your use of medications or other treatments. Family education and counseling can be helpful.

Conclusion

Treating pain can be complex. Do not try to diagnose your own pain. You may need to try several treatments before finding treatments that work for you. Start with the safest option. Sometimes, combining several pain treatment methods works best.

Ultimately, the solution may not be a cure. The goal of pain management is to make pain more tolerable and reduce its impact on your quality of life.

Guidelines for Pain Relief

• If pain begins, don’t wait for it to become severe before doing something about it.
• Learn which methods of pain relief work best for you. Vary and combine pain- relief methods. For instance, you might use a relaxation method at the same time you take medication for pain.
• Know yourself and what you can do. When people are rested and alert, they can use a method that demands attention and energy. When tired, a method that requires less effort may be useful. For example, try distraction when you are rested and alert, and use hot or cold packs when you are tired.
• Be open-minded and willing to try different methods. Keep a record of what makes you feel better and what doesn’t help.
• Sometimes you will need to try each method more then once. What doesn’t work one day may work the next. Don’t get discouraged, as not all methods will work for everyone.
• A question you should ask yourself is, “Does pain relief allow me to do what is important to me and those I care about?”

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Revised: 1/2015

This resource is provided as a courtesy of Craig Hospital. For more information, contact the Craig Hospital Nurse Advice Line at 1-800-247-0257.

Disclaimer: The content in this document is intended for general informational purposes only and is not a substitute for professional medical advice or treatment for specific medical conditions. No professional relationship is implied or otherwise established by reading this document. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Many of the resources references are not affiliated with Craig Hospital. Craig Hospital assumes no liability for any third party material or for any action or inaction taken as a result of any content or any suggestions made in this document and should not be relied upon without independent investigation. The information on this page is a public service provided by Craig Hospital and in no way represents a recommendation or endorsement by Craig Hospital.