Understanding Pain after Spinal Cord Injury

There are two main types of pain that occur after a spinal chord injury.

And these are quite different.

The first is acute pain which occurs immediately after the injury.

Many people experience this.

For example with surgery.

And then there's also chronic pain, which lasts… usually more than three months and certainly within six months after the injury.

And the important thing about chronic pain that's different from acute pain is that it can occur after the structures that have been damaged have undergone the normal healing process.

The reason we make the division between these different types of pain is that the mechanisms behind them are quite different.

And that means that they require different treatment.

So if we see somebody who has pain, it's very important for us to distinguish whether the pain is new or acute.

Or whether it's occurring on the background of a chronic or persistent pain condition.

It's really important for us in terms of treatment to assess people and work out exactly what sort of pain is going on.

And we know that pain takes various types.

One of these is musculoskeletal pain which occurs when muscles, tendons, joints, ligaments are inflamed or damaged or strained.

Some people also experience musculoskeletal pain below the level of their injury.

And if this happens it can feel quite different.

It may not have the same typical features of musculoskeletal pain above the injury.

Some people may not be able to experience it or describe it accurately.

But they may notice other things happening such as an increase in spasm, or possibly an increase in their neuropathic pain.

One of the other major types of pain that we see after spinal chord injury is what we call visceral pain.

Which is basically pain that is arising from inflammation or damage in the gut or in body organs.

The other type of pain we see is neuropathic pain.

And this is very common following spinal chord injury.

Neuropathic pain after spinal chord injury is very different from other types of pain.

And very different from musculoskeletal and visceral pain that we've just talked about.

And for a long time we didn't understand what was going on.

How could somebody who had a spinal chord injury, who didn't have any sensation below the level of their injury, experience pain in that area? And for a long time people and even, in some cases, health professionals doubted sometimes that people were experiencing real pain.

But in the last ten to twenty years there's been a huge focus of research around pain following spinal chord injury.

And now we have a lot more answers as to what is going on.

We know that there is damage to the nerves near the site of injury.

But one of the biggest causes, we now know causing neuropathic pain following spinal chord injury is damage to the spinal chord itself.

And there are a number of changes that seem to happen.

There are very small, what we call 'inhibitory neurones' within the spinal chord that normally block information traveling up the spinal chord to the brain.

What this means is that we have a natural gate that allows information going up towards the brain in the spinal chord.

And when these small inhibitory neurones are damaged this gate is left open.

So that in a sense there are more messages that are able to travel up the spinal chord.

and the spinal chord becomes sensitised to information so that people experience more pain.

In extreme examples that can mean that even things like light touch or sheets just touching the skin can actually cause pain.

And this is because the transmission system, the messages going up the spinal chord are not working in the normal way.

And in effect what is happening is that this gate is amplifying or turning up the volume on the pain.

The other thing we found out from research is that once there is damage to the spinal chord, there are new connections that form.

And although the body is trying to repair or to heal itself, actually there seems to be faulty wiring that also contributes to a persons' pain.

As well as changes in the spinal chord, we now also know that the brain changes after a spinal chord injury.

In effect what the brain is trying to do is to adapt to the loss of information that would normally come up the spinal chord.

And the brain is what we call plastic, it constantly changes.

So if there is information not coming up from the spinal chord in the normal way it would,… …the brain actually reorganises and changes the way that it works.

The problem is that it's been shown that once this reorganisation occurs it seems to result in pain.

Even after a spinal chord injury, it's still possible to use the principles of the gate and of volume control.

I mentioned before that after a spinal chord injury these small, inhibitory nerves get damaged that control the gate in our spinal chord and brain.

And during and after spinal chord injury, parts of this inhibitory system that control the gate remain significantly damaged.

And these changes and this damage can generate pain messages or amplify messages that are coming up the spinal chord.

The good thing about these gates in terms of control is that these gates are present in the spinal chord and also in the brain.

And what that means is that even if the gates are damaged in the spinal chord there are gates in the brain that can still control the amount of information and the amount of pain that is going up towards the brain.

And what is even more important in terms of being able to manage pain is that there are some very simple tools that can help to close the gate no matter what the level or type of spinal chord injury.

You can find some other very helpful information about how the brain and the spinal chord work in pain.

And also how the gates operate.

In another section of our website there is a video called 'Introduction to Pain' on the 'For Everyone' section of this website and if you go to there you'll find more information that tells you about some of these processes that are going on.

We used to think that the nervous system was fixed.

In other words, we thought it was a bit like… telegraph wires that transported messages from point A to point B.

We now know that the spinal chord and the brain are plastic, that they can change.

Either with pain or with spinal chord injury.

And that means that it varies according to the messages that are coming in.

So with… plastic changes, what happens is that there are what we call secondary changes that occur as a consequence of pain or spinal chord injury.

What that means is that as a consequence of the spinal injury there are changes that happen further up in the spinal chord or further up in the brain that contribute further to the pain.

The good thing is that some of these changes are reversible.

Again, they're not fixed.

The brain still remains plastic.

That's good information in terms of treating pain because it means that there are things that we can do to actually re-train the brain and reverse some of these plastic changes.

The good news that we've learned from this information around neuroplasticity and gates is that we now know that we have a range of very specific medications and also techniques that can help to close the gate and reduce the excitability in the nerves in the spinal chord after spinal chord damage.

And that means that we can reduce the pain.

The other thing is that we can also learn a range of strategies or skills that help to self-manage pain.

This means making the most of the body's own natural healing potential.

So trying one strategy isn't going to work.

Each of these skills and tools has a different target and to get the greatest benefit it's important to use them all in combination.

So things that we should definitely have in our tool box for helping with pain are… medications, which can reduce the hypersensitivity in damaged nerves… and also in the spinal chord.

Exercise and stretching.

These can help to reduce muscle stiffness, to help increase the range of movement and very importantly in terms of pain to release… …endorphins, our natural… morphines, that are contained in the brain and spinal chord and are released in response to exercise.

Also thought-challenging we know can help to retrain the brain.

Things such as meditation… …and relaxation.

These are techniques that help and optimise the body's ability to close the gates and to reduce the volume of pain messages.

We also know that rest, relaxation and sleep are hugely important in terms of managing pain.

If we have less sleep we know that pain can increase so it's important to try and get all of these as much as possible.

It's also good to have what we call a 'pacing plan' which means breaking up activities so that they don't result in increased pain.

It's also good to have some goals and thinking through how you might like to achieve those.

And also having a 'Pain Flare Up Plan'.

Ways of dealing with your pain when it becomes more severe than usual.

It's great to have some skills and some tools for managing pain.

But it's very important to be patient and persistent.

Some of these techniques do take a while to put into place and do take a bit of practice.

And changes aren't always going to happen overnight.

So it's important to put them in place and practice regularly and then after a while you'll start to enjoy the rewards.

So pain can be very complex and it may be helpful to have other people to learn some of these techniques and have a strong team around you.

There can be people like your GP, your case manager or your specialist who can form part of this team.

So you may find it helpful to go to the website and download the Health Plan which is available.

And take it along to your healthcare team and use this as a central communication device for all of the people involved in your care.