Pain characteristics in patients admitted to hospital with complications after spinal cord injury

Pain Characteristics in Patients Admitted to Hospital WithComplications After Spinal Cord InjuryHelen Barrett, Joan M. McClelland, RN, Susan B. Rutkowski, MB BS, Philip J. Siddall, MB BS, PhD

ABSTRACT. Barrett H, McClelland JM, Rutkowski SB,Siddall PJ. Pain characteristics in patients admitted to hospitalwith complications after spinal cord injury. Arch Phys MedRehabil 2003;84:789-95.

Objectives: To determine characteristics of pain, the rela-tion between pain and mood, the effect of pain on activities,and the perceived difficulty in coping with pain in patientshospitalized for treatment of complications associated withspinal cord injury (SCI).

Design: Cohort survey.Setting: Hospital inpatient unit in Australia.Participants: Consecutive sample of patients (N�88) ad-

mitted to a hospital spinal injuries unit with complications afterSCI. Two eligible patients declined to participate.

Intervention: Face-to-face interview with questionnaireMain Outcome Measures: Pain severity, global self-rated

health, mood (Kessler Mood Inventory), and interference withactivities (Von Korff disability scale).

Results: Sixty-six (75%) of the 88 subjects experiencedpain, with an average time of onset � standard deviation of8.02�12.4 years; 27% of those with pain described it as severeor excruciating. Subjects with pain were less likely to rate theirglobal health as excellent or very good when compared withthose who did not have pain (22% vs 44%, respectively).Patients with pain had significantly greater levels of psycho-logic distress than did people with SCI and no pain.

Conclusions: Pain is a common problem in people admittedto hospital with SCI for treatment of other complications. It hasa significant impact on activities and is associated with areduction in global self-rated health and higher levels of psy-chologic distress.

Key Words: Pain; Rehabilitation; Spinal cord injuries.© 2003 by the American Congress of Rehabilitation Medi-

cine and the American Academy of Physical Medicine andRehabilitation

CHRONIC PAIN IS AMONG the more problematic se-quelae of spinal cord injury (SCI).1-3 Several different

types of pain occur after SCI, and investigation and classifica-tion of the pain are difficult because of differing definitions ofpain types.4-7 The pain classification system we used in thisstudy identifies several types of pain associated with SCI,including musculoskeletal pain resulting from damage or over-use in structures such as bones, ligaments, muscles, interver-tebral disks and facet joints; visceral pain located in deep

visceral structures; neuropathic pain at the level of injury fromdamage to nerve roots or the spinal cord; and neuropathic painthat occurs below the level of injury and, as such, is possiblythe result of central nervous system changes after injury.8,9

Allodynia, pain produced by normally nonnoxious stimuli,10

was also examined separately.The reported prevalence of chronic pain in persons with SCI

is between 18% and 94%, with nearly one third experiencingsevere pain.4,7,9,11-13 The wide variation in the prevalence ofpain between different studies may stem from the subjectrecruitment and assessment procedure. The time since injuryalso varies widely between studies; some investigated the prev-alence of pain in the early phases after injury,9 during rehabil-itation,14 or at longer times postinjury in the community set-ting.13,15,16 The majority of these prevalence studies have beenconducted by surveys of community samples13,15-20 or a mix ofinpatients, outpatients, and patients in a rehabilitation set-ting.14,21-23

Psychosocial factors such as depressed mood, anger, andnegative cognition have been associated with increased painseverity after SCI.21,24-26 In particular, Cairns et al24 found thatpain and depression were not related when patients were ad-mitted to rehabilitation, but had become related by discharge.Cairns also found that alterations in pain had a more significantimpact on depression than the converse. Consequently, weincluded a mood inventory in this study to establish any rela-tion between pain and mood.

Chronic pain also has an important impact on quality of life(QOL) and function,16,17 with self-assessed QOL after SCIbeing lower in people who experience severe pain.27 Chronicpain also causes 75% of the distress experienced by patientswith SCI.21 QOL varies with time since injury, being lower inthose with SCI than in the unimpaired population for a periodof years after injury, then returning to normal levels.27 Richardset al26 found that pain that interfered with activities of dailyliving (ADLs) was associated with higher intelligence, olderpeople, depression, and a more negative psychosocial environ-ment. In this study, we assessed the interference of pain ondaily activities,28,29 as well as a global self-rated health mea-sure, and compared the effect of pain on other troubling se-quelae of SCI, such as pressure ulcers and sexual dysfunction.

A frequent sequela to SCI is repeated hospital admissions forongoing care of associated complications. Many of these ad-missions are related to pressure areas, infections, and boweland urinary tract problems. Although these are the primaryreasons for admission, prevalence figures suggest that many ofthe people admitted may also experience chronic pain. How-ever, no studies have investigated the prevalence, type, sever-ity, and relative importance of pain in patients admitted tohospitals with complications after SCI.

This study sought to determine the prevalence and charac-teristics of chronic pain in a series of inpatients admitted to ahospital for treatment related to their SCI. In addition, weassessed the effect of this pain on QOL and ADLs and assessedthe relation of mood to pain.

From the Pain Management & Research Centre, University of Sydney, Royal NorthShore Hospital (Barrett, McClelland, Siddall) and Spinal Injuries Unit, Royal NorthShore Hospital (Rutkowski), St Leonards, Australia.

No commercial party having a direct financial interest in the results of the researchsupporting this article has or will confer a benefit upon the author(s) or upon anyorganization with which the author(s) is/are associated.

Reprint requests to Philip J. Siddall, MB BS, PhD, Pain Management and ResearchCentre, Royal North Shore Hospital, St Leonards, NSW, 2065 Australia, e-mail:[email protected].

0003-9993/03/8406-7283$30.00/0doi:10.1016/S0003-9993(02)04944-4

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Arch Phys Med Rehabil Vol 84, June 2003

METHODS

ParticipantsWe performed a cohort study of consecutive patient admis-

sions to a hospital spinal injuries unit for treatment of compli-cations associated with established SCI. The study protocolwas approved by the institutional human research ethics reviewcommittee. Every patient admitted to the unit over a period of6 months and who was more than 6 months post SCI wasinvited to participate. Exclusion criteria are listed in table 1.Eighty-eight people were enrolled from a total of 110 admis-sions with established (�6mo) SCI (80% of those eligible).Verbal or written consent was obtained from all subjects in thepresence of a witness.

Survey ItemsA standardized questionnaire was completed with subjects

by face-to-face interview after they agreed to participate. Vari-ables related to SCI such as cause, level of injury, completenessof lesion, time since injury, reason for admission, and currentmedications or treatments being used for pain were noted.

Pain type was defined for each pain experienced by thesubject into 5 categories according to location, description,onset, and evoking stimuli.9 Musculoskeletal pain was definedas pain that was dull, aching, worse with movement, andappeared to be from musculoskeletal structures. Visceral painwas defined as pain that was spontaneous, dull, poorly local-ized or cramping, and apparently related to visceral pathology.At-level neuropathic pain was defined as having a burning,stabbing, electrical quality, and located in the dermatomesabove or below the level of injury. Below-level neuropathicpain was defined as burning, stabbing, shooting pain locateddiffusely below the level of injury. Finally, allodynia wasdefined as pain evoked by a nonnoxious stimuli such as lighttouch.10 Each pain experienced was rated for average intensityover the week on both a numeric rating scale (NRS), rangingfrom 0 (no pain) to 100 (pain as bad as it could be), and a verbalrating scale (VRS) with a 5-point adjective scale (none, mild,moderate, severe, excruciating).

Psychologic distress was evaluated by using a 10-item ques-tionnaire that included items on the level of anxiety and de-pressive symptoms in the previous 4 weeks.30 Items coveredthe range from minor symptoms to high levels of distress. Eachitem was evaluated by the patient by using a 5-point descriptivescale relating to the amount of time in the last 4 weeks that thepatient experienced the symptom. The scale ranged from “allthe time” to “none of the time.” The raw scores, which laybetween 0 and 50, were also converted to a T score with a meanof 50 and a standard deviation (SD) of 10. Scores of 60 or more

have been found to correspond to high levels of psychologicdistress using other health measures.31 Self-rated health wasevaluated with a global health measure that consisted of thequestion: Overall, how would you rate your health now: asexcellent, very good, good, fair, or poor?

In addition, for people with pain, the interference of pain onADLs, including work and social activities, was evaluated byusing the Von Korff chronic pain disability classification orChronic Pain Grade28 (CPG). This classification measures bothpain intensity and the impact of pain on normal activities. Itdivides subjects with pain into 4 categories that are based on acombination of pain intensity and disability measures. Grade Iindicates low disability and low pain intensity, grade II indi-cates low disability and high pain intensity, grade III indicateshigh disability and moderate limitation of activities, and gradeIV indicates high disability and severe limitation of activities.The level of disability is determined by a combination of thedays the patient is kept from usual activities by pain and thedisability score. This score is calculated from the questionsabout how much the pain has interfered with ability to work, totake part in recreational and social activities, and to continuedaily activities.

To gain some measure of the relative importance of pain inSCI when compared with other problems arising from SCI, arating was taken of the difficulty the subject experienced indealing with 10 common problems people encounter after SCI.These problems include pressure ulcers, bowel and bladderproblems, pain, and feelings of sadness. The difficulty thesubject had in dealing with each of the problems was ratedfrom 0 (not hard at all) to 10 (extremely hard).32

Data AnalysisData regarding pain severity and time of onset were com-

piled and presented as mean � SD. In the case of groupcomparisons, data are presented as means � standard error ofthe mean (SEM). Comparisons of global self-rated health rat-ings and scores obtained from the Kessler Mood Inventorywere made between the groups with and without pain. Com-parisons of group percentages were made by using chi-squaremethods and the Fisher exact test. A P value of less than .05was chosen to indicate significance.

RESULTS

Demographic DataDuring the period of the study, 110 people were admitted for

treatment with established SCI (�6mo since injury). Eightwere excluded for not meeting admission criteria (table 1) and2 declined to participate. Another 12 were not included becausethey were discharged from the hospital before an interviewcould be arranged. A total of 88 patients participated. Therewere no significant differences between the people in the studygroup and with those who were excluded: approximately 60%of each group had an injury at the cervical level and 35% hadan injury at the thoracic level. Eight percent of the group whoparticipated were injured at the lumbar level; there were nolumbar-level injuries in the missed group. The causes of injury,time since injury, and mean age did not differ significantlybetween the 2 groups. There were no significant differencesbetween the groups in any of the variables using chi-square ort tests. These data are summarized in table 2.

Prevalence of Pain

Sixty-six (75%) of the 88 subjects experienced pain. Calcu-lation of the number of different pains (whether location or

Table 1: Exclusion Criteria

Reasons for exclusion n

Difficulty with communication 2Psychiatric disorder 2Consent refused 2Age �18y 1Dementia 1Delirium 1Acute change in chronic SCI because

of ongoing pathologic process 1Discharged before interview arranged 12Total 22

790 HOSPITAL ADMISSIONS AND SCI PAIN, Barrett


type) showed that, of the 66 patients, 23 had only 1 pain (35%),43 experienced 2 or more pains (65%) with 22 having 3 (33%),6 having 4 (10%), and 3 people complaining of 5 differentpains (4.5%). For example, a subject might have had muscu-loskeletal pain in 2 places and another patient might have hadmusculoskeletal pain in 1 area and neuropathic in another. Bothpatients would have been placed in the group experiencing 2 ormore pains.

Musculoskeletal pain was the most common pain type; itwas experienced by 43.6% of subjects. This was followed bybelow-level neuropathic pain (24.3%), visceral pain (15.0%),at-level neuropathic pain (11.4%), and allodynia (5.7%). Sev-eral pain complaints had some relation to the reason for hos-pital admission (17.1% of all pain), for example, pain associ-ated with their current condition or postsurgical pain. Thesepains were included to obtain information about both theircurrent hospital admission and their ongoing condition. Whenevaluated according to pain types, pains associated with thehospital admission were primarily musculoskeletal (8.6% oftotal pain), visceral (7.1% of total), and below-level neuro-pathic pain (1.4% of total) (fig 1).

Onset of PainThe average time of onset of pain � SD was 8.02�12.4

years postinjury (range, 0.5–53y). Forty-seven percent of thesubjects had pain that began within the first year after injury.However, 27% of subjects had pain that began 10 or moreyears after injury (fig 2). Also of note was that 54.2% of thepain that developed 20 years or more postinjury was muscu-loskeletal in origin, 25% was visceral, 8.3% was at-level neu-ropathic, 8.3% was below-level neuropathic, and 4.2% wasallodynia.

Pain SeverityThe mean numeric severity score for all types of pain � SD

was 58.0�26.1 (maximum score, 100). The numeric severityscore was highest for visceral pain (65.8�21.6), followed byat-level neuropathic pain (58.8�24.5), musculoskeletal pain(57.4�26.7), below-level neuropathic pain (57.4�27.6), andallodynia (51.7�33.1).

Table 2: Demographic Data and Patient Characteristics for theIncluded and Excluded Groups

Subjects(N�88)

Missed(n�16)

Male:female 5.5:1 3.6:1Level (%)

Cervical 60 64.2Thoracic 32 35.7Lumbosacral 8 0

Injury cause (%)MVC 22.7 42.9MCA 9.1 14.2Diving/watersports 23.9 7.1Fall 19.3 7.1Nontraumatic (including stroke) 15.9 14.2Horse 3.4 0Other 5.7 14.2

Time since injury � SD (y) 16.68�12.6 11.7�10.4Age � SD (y) 48.4�13 45.5�14.2Reason for admission (%)

Pressure ulcers 26.7 14.2Intrathecal pump 12.8 0Urinary tract 15.1 14.2GIT 16.2 14.2Respiratory 3.5 7.1Musculoskeletal/surgery 12.8 21.4Cellulitis 4.7 7.1Pain assessment 1.2 7.1Other 7 14.2

NOTE. No significant differences were found between the groups(excepting group size, which was not tested). Sex, level of injury,cause of injury, and reason for admission were tested using achi-square test. For time since injury and age, a t test was used.The 14 patients whose demographic data are listed here does notinclude patients who were excluded because of age �18 years,dementia, delirium, and acute change in long-term SCI becauseof continuing pathologic process, nor does it include thosewith communication problems. It does include those who weremissed because of time constraints and those who declined toparticipate.Abbreviations: MVC, motor vehicle crash; MCA, motorcycle acci-dent; GIT, gastrointestinal tract.

Fig 1. Percentage of subjects who reported different types of pain.Also depicted is the percentage of those in whom pain was relatedto the hospital admission (unfilled bars) and those in whom painwas not related to the admission (filled bars). Abbreviations: AL-LOD, allodynia; MS, musculoskeletal pain; NAL, at-level neuropathicpain; NBL, below-level neuropathic pain; VISC, visceral pain.

Fig 2. Percentage of subjects who reported pain grouped by thetime of onset of pain after the initial injury.

791HOSPITAL ADMISSIONS AND SCI PAIN, Barrett


When a VRS was used, 27% of the subjects rated their painas severe or excruciating (fig 3). Subjects with at-level neuro-pathic pain or visceral pain were most likely to rate their painas severe or excruciating (38.5%, 37%, respectively), whereas26% of patients with below-level neuropathic pain and 23% ofthose with musculoskeletal pain described their pain in thoseterms. None of the patients with allodynia rated their pain assevere or excruciating.

Global Self-Rated Health and DisabilityNearly half as many subjects rated their global health as

excellent or very good when compared with those who werenot experiencing pain (23%, 44%, respectively) (�2�2.90,P�.05). However, the proportion of those rating their globalhealth as poor was similar in both the group without pain (19%)and the group with pain (20%) (fig 4).

The Von Korff CPG applies only to those with pain.29 Theaverage pain intensity score � SD was 59.4�20.4 (maximumscore, 100), and the average number of days the subject waskept from his/her usual activities was 30�55 in the last 6months. When the disability grade was calculated, 68.75% hada low disability score, with a low to high intensity of pain, and31.25% had a high level of disability (fig 5).

Rating of Pain Compared With Other ProblemsAll subjects rated their SCI-related problems. They reported

that the most difficult consequences of SCI were pressureulcers, followed by decreased mobility and decreased ability tocontrol the bowels. Pain was rated fifth, below infections andthe previously mentioned complications. The least problematicwas nonpainful abnormal sensations (table 3).

Mood InventoryWhen the Kessler Mood Inventory was used to assess psy-

chologic distress, patients with pain had significantly greaterlevels of psychologic distress than did those with SCI and nopain (mean raw scores � SEM, 21�1.0, 16�1.2, respectively,P�.002). Raw scores ranging from 0 to 50 were also convertedto a T score with a mean � SD of 50�10 to permit compar-isons with other populations. When this was done, 13.6% ofthose with pain and 11.1% of those without pain had a T scoreabove 60, which corresponds to high levels of psychologicdistress using other measures.

DISCUSSIONPeople with SCI often require hospitalization for manage-

ment of complications associated with their injury. The major-ity are not admitted for management of pain. However, ourstudy indicates that many of these people have chronic, oftensevere, pain that may have developed many years after theirinitial injury and now has a major effect on their perceivedgeneral health and ability to engage in activities.

Fig 3. Percentage of subjects who reported either mild or moderatepain or severe or excruciating pain grouped according to the type ofpain. Abbreviation: ALL, all types of pain.

Fig 4. Percentage of subjects with pain or without pain groupedaccording to categories of global self-rated health.

Fig 5. Percentage of subjects in each Von Korff disability grade.

Table 3: Problems Encountered After SCI, Listed in DescendingOrder of Perceived Difficulty

Problem Mean � SD

Pressure ulcers 4.7�4.2Decreased ability to walk and move 4.6�3.9Decreased ability to control bowels 4.1�3.6Infections 4.0�3.7Pain 3.9�3.2Decreased ability to control bladder 3.9�3.9Decreased sexual function 3.9�3.9Feeling sad 3.6�3.6Muscle spasms 3.4�3.3Abnormal sensations 1.5�2.5

NOTE. Rated on a scale from 0 (not hard at all) to 10 (extremelyhard).



In any survey, adequate representation of the entire samplemust be considered. For this reason, we chose consecutiverecruitment of admissions to avoid selection bias. Some pa-tients did not meet entry criteria, and 2 potential subjectsdeclined to participate. However, there was an 80% participa-tion rate, and there was no statistical difference between thecharacteristics of patients who completed the questionnaire andthose who did not. In addition, the demographic profile ofpatients was similar to that found in other studies, although ithad a slightly higher proportion of cervical level injuries thanon average (60% vs �50%) and few lumbosacral level inju-ries.9,13,15

The 75% of our sample that experienced pain was at thehigher end of the ranges reported in several studies that exam-ined pain prevalence in SCI populations during rehabilitation,while in the community, or while being seen in outpatientclinics.13,16,17,21,23 However, this percentage is similar to thecommunity prevalence of 79%18,19 and 80%20 reported in 3previous studies, and it is lower than that reported for a groupof patients in rehabilitation.14 The relatively high prevalence ofpain experienced by patients could be attributed to the fact thatthey were all hospital inpatients who had been admitted forvarious problems, including pressure ulcers, urinary tract in-fections, gastrointestinal problems, and orthopedic and othersurgical procedures, some of which resulted in pain. Whenthese admission-related pains were excluded, the prevalence ofpain was similar to that found in other community surveys.

The average time since injury for this group was more than16 years, and more than 25% of subjects had pain that hadcommenced more than 10 years after injury. Our findings arecomparable to those of Stormer et al,21 who found that painbegan within 1 year of injury in 58% of their sample, in 17%after 2 to 5 years, in 10% after 6 to 10 years, and in 13% aftermore than 10 years postinjury. Interestingly, although painbegan in 47% of subjects in the first year after injury, 15% hadpain that began 20 or more years after injury. In that group,musculoskeletal pain was reported by 54% of the subjects,indicating that the pain was probably associated with chronicmusculoskeletal problems or overuse syndromes. For example,in 1 study,33 nearly 60% of patients with SCI who responded toa survey experienced upper-extremity pain that was associatedwith transfers and wheelchair use. This is also consistent withthe results of studies that investigated aging and health in thispopulation and found an increased prevalence of upper-extrem-ity pain over time.34 Eight percent of subjects had onset ofeither at-level or below-level neuropathic pain more than 20years postinjury. Although this percentage was lower than thepercentage of patients who reported late-onset musculoskeletalpain, it nevertheless confirms that, in a substantial number ofsubjects, neuropathic pain can begin many years after the initialinjury, as described previously.11,35-37

The distribution of types of pain is more difficult to comparebecause of the lack of consensus among researchers in definingthe pain types. Musculoskeletal pain was the most commonpain type, followed by below-level neuropathic pain, visceralpain, at-level neuropathic pain, and allodynia. There is littleinformation with which to compare these figures on specificpain types at different time points. However, comparison witha study9 that used the same pain classification and investigatedpain prevalence at 6 months suggests that there is an increasein the proportion of patients with below-level neuropathic painand visceral pain. These increases may result from the lateonset of below-level neuropathic pain in some people and thedevelopment of bladder, bowel, and kidney problems withtime, thus giving rise to the higher level of visceral pain at thistime.

We made 2 estimates of pain severity by using a VRS and anNRS for pain. Visceral and at-level neuropathic pain were themost severe, with visceral pain having the highest numericseverity score, followed by at-level neuropathic pain, muscu-loskeletal, below-level neuropathic pain, and allodynia. Simi-larly, at-level neuropathic pain and visceral pain had the high-est proportion of severe and excruciating verbal scores, andallodynia had the lowest. Overall, 27% of our patients ratedtheir pain as severe or excruciating on the VRS, and 31% hadan NRS score above 70, indicating severe pain. This is lowerthan the 43% found by Stormer21 in a study with both in- andoutpatients but similar to that reported by others.4,9

However, even though more than 25% of our subjects wereexperiencing severe or excruciating pain, it was not the mostdifficult problem they faced. Pressure ulcers, decreased mobil-ity, and decreased ability to control the bowels were the mosttroublesome complications of SCI. The least problematic wasnonpainful abnormal sensations. Pain was fifth on the list. Acommunity survey of people with traumatic SCI found that themost difficult problems to deal with were decreased ability towalk or move, decreased sexual function, decreased ability tocontrol the bladder, and decreased ability to control bowel andpain. Pressure ulcers was the least difficult problem with whichto deal.32 The relatively high proportion of our sample thatrated pressure ulcers and infections highly most probably re-flects the fact that many of our patients were admitted for thesecomplications and their immediacy when surveyed. Wider-strom-Noga et al’s32 group was a community population andprobably in better general health than our group. Therefore, itis not surprising that decreased sexual function was higher ontheir problem list and pressure ulcers and infections were ofmore concern to our patient population.

Anxiety and depression have been previously associatedwith pain.21,38 Our study found that mood was significantlyworse in patients with pain than in patients without pain. It isdifficult to comment on causality based on this information.However, this finding is similar to that of other studies thatfound a strong relation between pain after SCI and psychologicvariables.25,26 In particular, Cairns et al24 found that althoughpain and depression were not related when patients were ad-mitted to rehabilitation, by discharge they had become related,and that alterations in pain had a more significant impact ondepression than the reverse.

Global health ratings differed between the 2 groups withnearly half of the number of patients with pain rating theirhealth as excellent or very good compared with the ratings ofthose without pain. Clearly, pain influences global health rat-ings by reducing the numbers of patients who perceive theirglobal health as being high. This may be interpreted in at least2 ways. It may be that pain has a direct negative impact onself-rated global health. Alternatively, pain may be more com-mon in people who have other problems, such as bowel andbladder problems or pressure areas, which also effect self-ratedhealth. Pain also influences QOL.15,27,39 Post et al39 found thatpain, pressure ulcers, spasms, and respiratory problems wererelated to poor life satisfaction. Lundqvist et al27 found thatalthough QOL scores were lower in the SCI population, thosewith older injuries had scores that approached those of theunimpaired population. Lundqvist also found that overall QOLperceptions were influenced only by severe pain. This is re-flected in our study by the smaller number of patients with painwho rated their health as excellent or very good.

Perhaps the more pertinent question for judging the impactof pain on hospitalized patients is the interference of pain intheir life before entering the hospital and during their stay. Weexamined this by using the CPG to measure the impact of pain



on ADLs. In this study, 17% of the subjects were categorizedas Von Korff grade IV, which indicates high levels of disabilityassociated with pain. This can be compared with the 17% ofback pain patients, 10% of headache patients, and 5% oftemporomandibular joint pain patients previously found tohave grade IV, severely limiting pain.29 Thus, even in patientswho already have major impairments, pain itself has a majorimpact on their ability to engage in activities. Interestingly,45% of our group was experiencing high levels of pain but lowdisability (grade II), which can again be compared with the28% of those who experienced back pain, the 40% who hadheadaches, and the 43% who had temporomandibular jointpain.29 Therefore, although pain has a major effect on activitiesfor some people, there are still a large number of people withhigh levels of pain that have little impact on their level ofactivities.

There have been efforts to examine disability arising fromchronic pain that have had equivocal results. Nepomuceno etal17 found that 44% of people at least 12 months after SCI whowere living in the community had pain that interfered withdaily activities, whereas 31% did not report interference. Wid-erstrom-Noga et al40 found an even higher proportion, with77% of the people in a community sample reporting that painfrequently interfered with 1 or more daily activities, includingsleep, work, exercise, and household chores. However, Stormeret al21 found that 23% of their sample experienced pain that hadno effect on daily activities, whereas 23% were severely lim-ited. Stormer also noted that there were patients who, althoughexperiencing pain that was severe, stated they were unwillingto allow the pain to restrict their activities. This attitude wasalso encountered in several of the patients in our study.

CONCLUSION

Chronic pain is a common problem for people with SCIalthough it may not be the primary reason for admission to ahospital. Its impact, however, is substantial. First, more than25% of these people describe their pain as severe or excruci-ating. Second, pain is significantly associated with increasedlevels of psychologic distress, and people with pain are lesslikely to rate their health as excellent or good. Third, althoughpatients with SCI face major obstacles, such as loss of mobility,pain rates highly as a difficult complication of SCI, and innearly one third, pain alone was the cause of high levels ofdisability. Efforts that result in an increased understanding andimproved management of chronic SCI pain will produce asubstantial reduction in suffering and will enhance the QOL formany people with SCI.

Acknowledgments: We thank Dr Bonne Lee and Dr Fiona Blythfor their support and help during the study.

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Documents

Pain characteristics in patients admitted to hospital with complications after spinal cord injury