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Australia: Pain following spinal cord injury.

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  • Australia: Pain following spinal cord injury.

    Siddall PJ and Loeser JD (2001). Pain following spinal cord injury. Spinal Cord. 39 (2): 63-73. Summary: Chronic pain is an important problem following spinal cord injury (SCI) and is a major impediment to effective rehabilitation. The reported prevalence of chronic SCI pain is variable but averages 65% with around one third of these people rating their pain as severe. The mechanisms responsible for the presence of pain are poorly understood. However, evidence from clinical observations and the use of animal models of SCI pain suggests that a number of processes may be important. These include functional and structural plastic changes in the central nervous system following injury, with changes in receptor function and loss of normal inhibition resulting in an increased neuronal excitability. A number of specific types of SCI pain can be distinguished based on descriptors, location and response to treatment. Nociceptive pain can arise from musculoskeletal structures and viscera and neuropathic pain can arise from spinal cord and nerve damage. The role of psychological and environmental factors also needs to be considered. Accurate identification of these pain types will help in selecting appropriate treatment approaches. Current treatments employ a variety of pharmacological, surgical, physical and psychological approaches. However, evidence for many of the treatments in use is still limited. It is hoped that future research will identify effective treatment strategies that accurately target specific mechanisms. <> Pain Management and Research Centre, University of Sydney, Royal North Shore Hospital, Sydney, Australia.

  • #2
    Moved to <>.


    • #3
      Phil Siddall is Australia's brain trust on central pain and a true friend of those with SCI. In a world that does not believe central pain exists, he continues to remind people that it does. We must have Congress pass a law that no neurology text may be sold which does not have a section on central pain. Those trained neurologists who do not know about central pain can be such an annoyance when you go to see them. I don't deface these texts in the medical bookstore as I watch new editions come and go, without mentioning the most severe pain state known to man, but you will hear me muttering phrases which indicate I have lost my religion when I see big thick expensive neurology texts which make no mention. Another generation of neurologists who need a good lecture from Dr. House to know about pain is thus released on the unsuspecting public.

      I respectfully disagree, however, that psychology is in any way involved in causation of central pain. This is a holdover from the old ideas of the medial and lateral pain systems in the thalamus and limbic system.

      Psychology is code for "relax". In the old days, when doctors did not know much about hormones, infertile women were told to relax. For this advice, doctors were paid money. I see no evidence that today's women are any more relaxed, but they nearly all are able to conceive now with gonadotrophin regulation and insemination with fertilized ovum (bringing modern ob/gyn to where veterinary medicine was in the 1940's). Medicine always thought women had hysteria and named their organs accordingly. However, this idea is passe. Those of us who knew nothing of SCI pain, who were reasonably well adjusted until our SCI, and then found a ghastly physical sensation appearing (accompanied by some which were just painful), which we could not imagine if we were paid to do it, must remind the profession that it is very unlikely psychology is causing central pain. However, central pain certainly causes psychology.

      Clinicians who have to deal with the emotional fallout from really terrible pain, and ponder how it might compare to say, severe pain, find themselves in a quantifying dilemma. There are only so many pain words and everyone uses the same ones. Although Central pain sufferers have sensations that no other humans experience, they have to use words of ordinary pain. There are no other words available. There is no vernacular for central pain. A doctor would have to be smart indeed to discriminate the Central Pain patient who is using inaccurate words because he has no choice.

      The discussion, if hurried, can be taken as resembling the overreacting or somaticizing patient, whose condition is footed on some psychological problem. Since pain talk is usually precise, the imprecision of Central Pain description leads to a perception that the patient does not really have pain. Of course, they do not, since central pain is NOT pain. It is nevertheless a noxious and agonizing mix of sensations and physical discomfort. Having had the motion segments of the spine messed up in many ways, the CP patient usually has ordinary pain, and there will certainly not be time to sort this out from the neuropathic elements during the visit. It will also usually not be sorted out on follow up to evaluate therapy and medications. There is never enough time to do these things.

      Years ago, I participated in surveys of CP patients, oral and written, in a search for verbal descriptors. They were all over the map. However, if we asked intelligent questions, a readable pattern emerged. it was still very difficult. One could distinguish dysesthetic burning, lancinating pain, spontaneous and evoked burning, pins and needles, kinesthetic dysesthesia, isometric dysesthesia, etc. But it took a LOT of time. A "lot of time" is not going to be available in managed care, so there is poor understanding of how central pain is structured. The patients themselves were of little help until the proper cues were provided and they were compelled to be specific. Typically, the patient simply referred to their "pain". When asked if it was like any other pain in quality, they said "no", as if that was not a particularly important question. When asked why they were using the word "pain" if it was unlike ordinary pain, they seemed puzzled and annoyed and went back to using terms which gave no information about quality. They wanted to tell how BAD it was, but they didn't want to talk about what KIND of pain they were having. Patients in terrible pain are actually rather poor historians because they are concerned about severity, not quality of pain. This "incoherency" also tends to make doctors, who think the patient would be only too glad to describe the various aspects, think the patient has psychology. Doctors must provide the words and educate the patient what those terms mean before they will get a history that is helpful. And of course there are a considerable proportion of patients who do have psychological dysfunction with respect to the pain. Unremitting central pain can make any of us sound gaga after a while. The end point is often refusal to discuss the pain. Others are not going to understand it anyway. Not talking is sort of like dying with dignity. Pain descriptors need to be refined.

      If you could trust words, you would have to conclude that tension headaches amenable to NSAIDS were the worst pain known to man, or at least life destroying. TV ads do such a good job with the language, PLUS there are those drawn-in electric circles of pain radiating from the actor's head. or wherever. What is the poor doctor to do. Some patients are brave, some are not. Some have a stable life and some do not. This the doctor sees and this he reacts to. Lacking a device to measure actual pain, the clinician cannot help confusing apples with oranges. Those who go to pain clinics all feel their pain is significant. Some of them have a definite psychological overlay. Not having seen the patient at the time central pain appeared, how would the doctor know that psychology was causative. As in, I see you are crying now that your relative is dead--the autopsy being inconclusive, you must have caused your relatives death.

      This can sound very much like shaman medicine and the offended evil spirits that need to be appeased or exorcised. Sophisticated patients who know very well that what they are feeling is not psychological can become highly offended. Doctors attributing Central Pain to the mind/body may resemble the witch doctor who performs some ritual to drive out some ethereal bad thing from the patient, who is not ill but irreligious. Retroactive psychological conclusions have a way of turning out to be physician ignorance when science does its work.

      When we can measure pain, and even better, treat central pain, talk of psychology will fade. Relaxed or not, we have terrible sensations, way more glia around our neurons in the pain tracts and quadruple the amount of neuroinflammatory chemicals along the axons and in the synapses. My money is on this as cause, rather than my fetish for suffering. In the homeostasis loving human body, four times increase in anything, is significant.

      Doctors are smart people. If we gave them half a day to talk to Central Pain patients, they would begin to understand and differentiate the various central pains. This is not going to happen with the fifteen minute maximum which managed care allows. One solution would be to have a technician who is trained in the various elements take a careful history. This would be far more scientific than the "rate your pain 1 to 10" that is going on now.
      Last edited by dejerine; 08-05-2011, 04:27 PM.


      • #4
        I been told my spinalcord has been severed and my pain is great through out the day, almost everyday.. I had went to Kessler and the head of the pain management sat down and told me I have no pain and for me to detox in 2 months. degrading and insulting me. They had to call security after I was done. I had wrote the medical board against a past pmr dr. for releasing me of his care and he knew the guy. I cant believe how they treated me and I was kick out. My pain is so bad I would love to rid of it so I can be more active. Like Larry Flint has done 10 yrs in pain and got sugery done and he said it was the greatest feeling not to feel such pain.
        life begins when you walk in spirit


        • #5
          I can't accurately describe the pains I feel. Heck, if I can't believe the the sensations I feel, how can I expect someone else to?

          Proofread carefully to see if you any words out.