Introduction

With paraplegia, one wakes up every day to fight for survival. For the paraplegic, there is a constant need to handle the pain and maintain quality of life. What if there was a way to overcome that pain? The ability to finally unlock the secrets to managing pain effectively, giving paraplegics an opportunity to take their life back? Paraplegia refers to the paralysis of the lower half of the body, usually due to damage to the spinal cord as a result of injury or sickness. Paralysis of the legs and parts of the lower body, loss of motor and sensory function, reduced mobility, balance, and coordination, and, in extreme cases, reliance on assistive aids like wheelchairs characterise paraplegia.¹ Pain is one of the most common and disabling complications of paraplegia. There are various kinds of pain associated with paraplegia, like neuropathic pain, nociceptive pain, and other unknown types.² These pains can significantly affect the quality of life, leading to depression, sleeping disturbances, and less participation in everyday activities. In fact, proper pain management is very instrumental in enhancing the quality of life of those living with paraplegia.

Types of pain in paraplegia

Different types of pain, such as neuropathic pain and nociceptive pain like musculoskeletal or visceral, are typical in patients with paraplegia.

Neuropathic pain (nerve pain) is the most common form of pain experienced due to direct damage to neural elements in individuals suffering from paraplegia. This is a generally incapacitating condition with predominantly burning, shooting, or electric-like feelings that may be of great intensity. The degrees of neuropathic pain are vast, from mild discomfort to extreme agony, thus affecting the quality of life.³

Another common complication that most people with paraplegia suffer from is musculoskeletal pain, which is a subtype of nociceptive pain. This condition may be caused by muscle spasms, joint pain, or pressure sores that are developed from long periods of immobility. Muscle spasms can be very painful and disruptive since there is no warning before the spasm and it may contract sharply. Joint pains can persist especially in weight-bearing areas while sitting in a wheelchair such as the hips, knees, and ankles.⁴

Patients with paraplegia may also report visceral pain, another type of nociceptive pain which involves a dull, aching pain deriving from the abdominal internal organs. At a diagnostic and therapeutic level, this can be very challenging as the pain signals could be misinterpreted, making it hard to identify the correct source of the pain and assume it is originating from the wrong location. For example, paraplegia sufferers may experience pain in the bladder or bowel but the pain could be hard to differentiate from other types of discomfort and it may feel like it is coming from somewhere else.⁵

Assessment of pain

Effective management of the pain should begin with an accurate assessment of the pain in paraplegic patients. Healthcare professionals use a different array of tools and methods in order to understand the pain experience of every patient.

One of the most commonly used methods incorporates the use of self-report scales, the Numeric Rating Scale, and the Visual Analog Scale. They are very simple yet strong tools which the patient can use to measure their levels of pain on a scale from 0, indicating no pain, to 10, indicating the worst pain imaginable. Serving as a verbal or visual description, quantification of discomfort can be given to express the degree of pain a paraplegic patient feels to a health team, which will be able to work out more focused and specific decisions regarding treatment.⁶

This can also be further assessed using self-report scales and pain diaries. The pain log details with respect to the frequency, duration, and precipitating events of painful episodes over any given period. This information can help in identifying patterns, underlying causes, and possible perpetuation variables that will help in formulating a pain management plan.⁷

Moreover, healthcare professionals might also, in addition to these subjective measures, examine patients with a diagnosis of paraplegia physically to evaluate their experiences of pain. Sensory testing, such as assessment of touch, temperature, and vibration perception, and an assessment of the tone in muscles and range of motion in joints, are only some of the possible examinations. Such objective findings, combined with self-reported experiences by the patient, give a more holistic gist to the pain and its effects on general function and quality of life.⁸

The assessment of pain in paraplegia holds the key to effective management. Healthcare professionals incorporate these varied tools and methods to individualise treatment and address the needs of the patients, thereby improving their g general well-being and alleviating symptoms.

Pharmacological pain management strategies

Pharmacological strategies for pain management involve the administration of different medications to manage the different types of pain in people suffering from paraplegia. The drugs act on specific mechanisms or pathways within the body, thereby altering the pain signals and improving overall pain control.

Neuropathic pain medications⁹

• Anticonvulsants (e.g., gabapentin, pregabalin)
• Antidepressants (e.g., duloxetine, tricyclic antidepressants)
• Topical agents (e.g., lidocaine patches)

Musculoskeletal pain medications⁹

• Muscle relaxants (e.g., baclofen, tizanidine)
• Nonsteroidal anti-inflammatory drugs (NSAIDs)

Opioid analgesics

In patients with paraplegia, the use of opioid analgesics, such as morphine or oxycodone, may be necessary in cases of severe or refractory pain. These painkillers are very effective, acting on certain receptors in the brain and spinal column, therefore minimising the transmission and perception of signals of pain. In cases where all other pharmacological and non-pharmacological treatments have proven inadequate, opioid analgesics can benefit unfortunate individuals who endure intolerable levels of pain. However, opioid medications are rarely used for the treatment of paraplegia because of the significant risks involved with their long-term use. Long-term exposure to opioids can lead to physical dependence and addiction because increasing tolerance of the body to their effect is built up. This can lead to an escalating dosage cycle with serious side effects, such as confusion,  respiratory depression, constipation, and cognitive impairment.⁹

Furthermore, it is also possible that a heightened risk of adverse opioid-related events in individuals with paraplegia is driven by complex interactions between the drugs and underlying neurological and physiological processes of this condition. Of these, reduced mobility, altered metabolism of drugs, and the presence of comorbidities can all contribute toward increasing the susceptibility of these patients to the unfavourable aftereffects of opioids.⁹

Non-pharmacological pain management strategies

The well-established arsenal of non-pharmacological pain management strategies is used in conjunction with pharmacological approaches to create a more comprehensive pain management plan. These practices include:

Physical therapy¹⁰

• Stretching and strengthening exercises
• Electrical stimulation (e.g., transcutaneous electrical nerve stimulation, TENS)
• Massage therapy

Psychological interventions¹⁰

• Cognitive-behavioral therapy (CBT)
• Relaxation techniques (e.g., meditation, deep breathing exercises)

Complementary and alternative medicine¹¹

• Acupuncture
• Herbal remedies
• Massage therapy

Interventional pain management

In some patients, interventional pain management techniques can be utilised to deal with paraplegia-related pains. They involve minimally invasive procedures that in most cases target an identifiable pain generator.¹⁰ The following are examples of interventional pain management techniques: 

• Intrathecal drug delivery systems (e.g., baclofen pumps)¹²
• Spinal cord stimulation
• Nerve blockers

Challenges in paraplegic pain management

Whilst there have been so many important advances in pain management strategies amongst those with paraplegia recently, there are simply too many issues standing in the way of effective chronic pain management in paraplegia. In the first place, barriers to meaningful access to specialised pain management services pose a great challenge, especially in underserved or rural areas.¹³ In places where no multidisciplinary teams trained to care for this type of patient exist, it can prove very hard for a person with paraplegia to get the necessary care that is needed. Moreover, the creation of individualised treatment plans is hindered by the fact that this is a quite heterogeneous and complex disorder, and pain patterns differ greatly from one patient to another.

Control of the effects through medication is another major challenge. Most pharmacological interventions that can be done to relieve pain such as antidepressants and anticonvulsants are often accompanied by possible side effects. These can possibly worsen the quality of life of the patient.¹⁴ A balance between the benefit of pain relief versus potential risk should be carried out carefully, with close follow-up to maintain adjustments in the treatment regimen.

Indeed, pain assessment might be very challenging in patients with paraplegia, particularly if there are additional complications, for example, cognitive deficits or a language barrier. Precise methods for quantification and follow-up of the patient's pain experience are of great value in guiding therapeutic decisions but may constitute a complex and subjective process that requires special expertise and specifically adapted assessment tools.

Summary

Paraplegia is paralysis of the lower body, which means that invariably there will be chronic pain. Physicians make use of several assessment tools to suggest treatment interventions on an individual basis. The treatment strategies vary from pharmacological measures such as anticonvulsants and antidepressants to non-pharmacological or non-interventional therapies like physical therapy and psychological intervention measures. Interventional approaches in more resistant or stringent pain include methods such as intrathecal drug delivery systems. Tailored plans can be made by combining these treatment strategies to improve patient outcomes and alleviate their debilitating symptoms.