Pain after Injury

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

There are numerous causes of pain some examples are broken bones (either with or without surgery), injured joints and muscles or damaged nerves. Movement of muscles and joints after periods of non-use also can 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 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.

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 in understanding the different causes of pain and the different treatment options.

Pain Relief 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

Types of Pain

There are two types of pain – acute pain 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 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 it.

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 vary and can range from dull to sharp or achy to throbbing. It usually involves some type of physical cause such as physical injury to the muscle, joint or bone. This type of pain can happen to anyone. However, spasticity, a condition where the muscles have a difficult time relaxing because of SCI or BI, is also a common cause of mechanical pain.

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 be a sign 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 or may not 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 and 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) relates to the distinct pattern of pain with SCI, where 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 that the area(s) involved may be overly sensitive to touch, also known as hypersensitivity. It is believed that the damage to the nerve roots at the level of injury causes this type of pain. Again, this condition does not necessarily indicate that there is worsening of the injury.

Cyst (Syrinx) Pain

When the spinal cord is injured, sometimes a fluid filled cavity can form within the spinal cord itself, and this is called a cyst or syrinx. The cyst can sometimes expand up or down the spinal cord and 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. While this condition is not common and only occurs in SCI it can be very serious and is another reason why it is important to discuss all pain issues with your team.

Treatment of Pain after Injury

Treatments vary, depending on the type of pain. While research continues in pain treatment, no significant data proves one method as the standard treatment for pain control in every individual or for every situation.

Acute Pain Treatment

Acute pain usually responds well to treatment involving a combination of strategies, including medications, physical treatments, as well as counseling. Mental focus involves resolution or elimination of pain and ways to prevent the pain from happening again. For this type of pain, treatment is usually “after-the-fact”; meaning that you first report the symptoms before something is done about it.

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 on the surface of 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 or 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 refer to a drug being injected directly into the skin or spine. This method has fewer side effects than narcotics and the pain relief last longer. Doctors often use these treatments before neurosurgery because the risks are lower.

Dorsal root entry zones (DREZ)

DREZ is a neurosurgical procedure for reducing pain in some individuals. The DREZ procedure involves thermally heating parts of the spinal cord or nerve roots thought to be the source of pain. There is a greater than 80% success rate for selected cases of paraplegia.

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 trained, certified massage therapist (CMT) may also help in relieving pain due to muscle tightness and muscle imbalance. Speak with your doctor if you are interested in massage therapy.

Acupuncture

Pain specialists in the treatment of chronic pain have used acupuncture treatments. 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 as important. With psychological approaches, you are an active participant and can actually affect your pain by becoming more involved in the management of pain through learning 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

There are other factors that can aggravate pain, such as 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 most important. Inactivity and boredom allow 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. This can change your entire lifestyle.

You want to decrease your pain so you can safely participate in as many activities as possible. If you limit your activities, it may only make things worse. Consult with your doctor to find out the type and cause of your pain. Ask what you can and what you cannot do.

Pain is an invisible disability and family members may not understand your pain. Because of their concern, they may be overprotective or resent your use of medications or other treatments. Family education and counseling can be helpful.

Conclusion

Pain and its treatment can be a complicated problem. Do not try to diagnose your own pain. You may need to try several treatments before finding one, or a combination, which works for you. Start with the safest option. Often, combining several methods may work.

Ultimately, the solution may not be a cure. It may be learning new or improved skills to make the pain more tolerable and reduce the impact of pain on your quality of life.

Guidelines for Pain Relief

• Prevent the pain before it starts or gets worse by doing some pain-relief methods on a regular schedule. If pain begins, don’t wait for it to get worse 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. Often when people are rested and alert, they can use a method that demands attention and energy. When tired, they may need to use a method that requires less effort. For example, try distraction when you are rested and alert, use hot or cold packs when you are tired.
• Be open-minded and keep trying. Be willing to try different methods. Keep a record of what makes you feel better and what doesn’t help.
• Try each method more than once. If it doesn’t work the first time try it a few more times before you give up. Keep in mind what doesn’t work one day may work the next. Also, you might need help in figuring out the best way to use a certain technique. Don’t get discouraged if a certain method does not work for you. People are different, and not all methods will work for everyone.
• Most important, always ask yourself: “Is the cure worse than the disease? Does pain relief allow me to do what is important to me and those I care about?”

Related Resources

This resource is provided as a courtesy of Craig Hospital.

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 resource’s 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.