SMOKING REDUCTION AND CESSATION IN THE BOROUGH Introduction Smoking is one of the major preventable causes of illness and death. At the Borough Partnership in June 2004, the Council was asked to prepare a paper to explore what more could be done locally. This paper examines the national and regional background in which smoking policiesare being developed. It describes the national, regiona
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Sci-pain.inddThe problem of pain after SCIPain is a serious problem for many people with spinal cord injuries (SCI). Pain after SCI can occur in parts of the body where there is normal sensation (feel-ing) as well as areas that have little or no feeling. The pain is very real and can have a negative impact on quality of life. A person in severe pain may have dif-fi culty carrying out daily activities or participating in enjoyable pastimes. The majority of people with SCI report that they have chronic pain. Chronic pain is pain that does not go away and instead lasts months to years. The cause of the pain may be unknown but is most often related to nerve damage from the SCI or musculoskeletal problems that arise in dealing with an SCI. The pain can come and go. Chronic pain is diffi cult to completely eliminate but often can be managed or reduced enough so that it doesn’t overwhelm your life.
Chronic pain can cause or worsen psychological problems such as depression, anxiety and stress. This does not mean the pain is “all in your head,” but rather that pain and distress can make each other worse.
Even though pain after SCI can be complicated and diffi cult to treat, there are many treatments available that can help. Understanding your pain, working with your doctor and being open to a variety of treatments will help you manage your pain and improve your quality of life. Many people with diffi cult chronic pain prob- lems after SCI have found relief using techniques described here.
Types of painA person with SCI can have many different types of pain in different locations, including areas where there is not usually any feeling. Understanding what type of pain you have is key to choosing the right treatment. Therefore, your doctor will ask you to describe your pain in a variety of ways, including its locations, severity, how long you have had it, what makes it worse or better and so on. Your doctor also may ask you to undergo tests such as an x-ray or MRI (mag- Neuropathic pain (“neurogenic pain”) is caused by abnormal communication between the nerves that were damaged by your spinal cord injury and the brain, where nerve signals that inform your brain how your body feels are in- terpreted. In neuropathic pain, it is thought that the brain “misunderstands” or amplifi es the intensity of the signals it is getting from around the area of your injury. This can cause you to experience pain coming from areas of your body below where you have little or no feeling. This is why a person can feel neuro-pathic pain in an area that otherwise has no feeling. Spinal Cord Injury Model Systems Consumer Information
Copyright 2009 Model Systems Knowledge Translation Center (MSKTC).
People often use words such as burning, stabbing or tingling to describe neuropathic pain, but neuro-pathic pain varies a great deal from person to per- Visceral pain is located in the abdomen (stom- son. It is often very diffi cult to treat, and frequently ach and digestive area) and is often described as a combination of treatments must be used.
cramping and/or dull and aching. It can be caused by a medical problem such as constipation, a kid- Note: If pain starts years after injury, it may be ney stone, ulcer, gall stone or appendicitis. Since a due to a new medical problem, such as a syrinx, person with SCI may not have the usual symptoms a fl uid-fi lled cavity that forms in the spinal cord. associated with these medical conditions, it is im- It is rare but may require surgery. Therefore, it is portant to see a doctor who has had experience very important to contact a doctor if you notice caring for SCI patients in order to get a correct any new loss of sensation, especially in areas around the level of your injury, and any muscle Pain that comes from a visceral problem is some- weakness that doesn’t improve with rest.
times felt in an area away from the source of the problem. This is called referred pain. One common Musculoskeletal pain is caused by problems in the example is shoulder pain that results from gallblad- muscles, joints or bones. It is a common problem for all people as they get older, including those Since pain can have so many different causes there Musculoskeletal pain can be caused by injury, over- is no single way to treat it. You and your doctor use or strain, arthritic changes, or wear and tear may need to try a combination of drugs, therapy of the joints, often from wheelchair use (including and other treatments, including psychological treat- inadequate support for sitting) and/or transfers. It ments, and this may take some time to work out. usually gets worse with movement and better with rest. Upper limb (shoulder, elbow and hand)
Activity modifi cation for musculoskel-
pain is often caused by overuse of the muscles
etal pain. Changes in your mobility equipment
from doing transfers and pressure relief maneu- (wheelchair, sliding board), your wheelchair vers and from pushing a wheelchair. It can occur pushing and transfer techniques, and in the way months or many years after injury. People with you do pressure reliefs can signifi cantly decrease higher level injuries who use computers or joy- pain in your muscles and joints. Exercises that sticks for many activities (reading, communicat- strengthen and balance your joints can also help ing, environmental controls) may develop pain in reduce musculoskeletal pain. For information, the hand, arm or shoulder from overuse. Upper please see the supplement “Activity Modifi ca-
limb pain can make it diffi cult for you to transfer tion for Musculoskeletal Pain.”
safely and perform other activities of daily living. Physical therapy is used to treat musculo-
Back and neck pain are common problems.
skeletal pain. Stretching and range of motion In people with paraplegia who have had surgery exercises may help relieve pain associated with to fuse their spine, increased motion that occurs muscle tension. Exercises that strengthen weak just above and just below the fusion can lead to muscles can restore balance in painful joints and back pain. People with tetraplegia (quadriple- gia) may also have back pain, especially if they Therapeutic massage may help relieve mus-
Spinal Cord Injury Model Systems Consumer Information
are able to walk but still have weakness. People culoskeletal pain due to muscle tightness and who use chin- or mouth-operated joysticks may Acupuncture is used to treat musculoskeletal
Muscle spasm pain happens when muscles
pain. Tiny needles are inserted into the skin and joints are strained from spasticity. at specifi c points on the body. This method is thought to work by stimulating the body’s pain Antiseizure medications such as gabapentin
control system or by blocking the fl ow of pain.
(Neurontin) and Pregabalin (Lyrica) are used to Transcutaneous electrical nerve stimu-
treat neuropathic pain. Side effects include dizzi- lation (TENS) is sometimes used to treat
musculoskeletal pain. Electrodes are placed on Antidepressants are used to treat neuropathic
the surface of your skin and send low levels of pain and depression. These medications include electrical current into your body. The current selective serotonin norepinephrine reuptake blocks signals from the areas of nerve damage inhibitors (SSNRIs), such as venlafaxine (Effexor), and tricyclics, such as amitripltyline (Elavil). Side effects include dry mouth, sleepiness, dizziness and (with SSNRIs) nausea.
We now know that people can learn to use psy-chological techniques to help them manage their Narcotics (opiates) such as morphine, co-
pain better so it doesn’t take over their lives. deine, hydrocodone and oxycodone are used Psychologists trained in pain management can help to treat neuropathic and musculoskeletal pain. with a variety of techniques proven to be effective These drugs have many side effects, including in reducing the intensity and impact of pain.
constipation and sleepiness, and can be habit forming. You may also develop dependency on Relaxation techniques and/or biofeedback
these drugs and may have withdrawal symptoms designed to teach you how to reduce muscle if you suddenly stop taking them. However, they pain tension and “mental tension” associated can be used effectively for many people, and with pain can be helpful in self-management.
while not the fi rst consideration for chronic pain Self-hypnosis training has proven helpful for
management, should not be dismissed because reducing chronic pain in some individuals.
of fears about dependency or side effects Cognitive restructuring. Learning how to
Muscle relaxants and anti-spasticity medi-
think differently about your pain and its effects cations such as diazepam (Valium), baclofen can actually lead to changes in brain activity and, (Lioresal) and tizanidine (Zanafl ex) are used to treat spasm-related and musculoskeletal pain. Individual psychotherapy designed to help
These may be taken by mouth or delivered identify desired goals and increase pleasure and directly to the spinal cord through an implanted meaning in daily life can help reduce pain. Ther- pump (see “Intrathecal pumps” below). These apy can also help if there is a signifi cant amount drugs can cause sleepiness, confusion and other Topical local anesthetics such as lidocaine
There are many different medications to treat pain. (Lidoderm) are used to treat pain that occurs All of the medications listed below have shown when skin is lightly touched (called allodynia). some success in reducing pain, but none do so completely in every instance. All have possible side effects, some of which can be serious. Discuss all Dorsal column stimulator is used to treat
side effects with your doctor. Sometimes combina- neuropathic pain due to nerve root damage. A tions of drugs work better than a single drug. high frequency, low intensity nerve stimulator is surgically placed in the spinal canal next to the Non-steroidal anti-infl ammatory drugs
Spinal Cord Injury Model Systems Consumer Information
(also known as NSAIDs) such as aspirin, ibupro-fen (Motrin, Advil) and naproxen are most com- Intrathecal pumps are used to treat neuro-
monly used to treat musculoskeletal pain. Side pathic pain (using morphine) or muscle spasm- effects may include stomach upset or bleeding related pain (using baclofen) A pump containing morphine or baclofen is surgically placed under the skin in the abdomen. It delivers the medica- a high-strength, fully customizable chair made of tion directly to the spinal cord and nerve roots. the lightest material possible (aluminum or tita- nium). Learn the proper wheelchair propulsion (pushing) technique from a physical therapist. Get treatment for medical problems.
(See the supplement “Activity Modifi cation
Overall health can have a big impact on pain. for Musculoskeletal Pain.”)
Urinary tract infections, bowel problems, skin Do not use alcohol to ease pain. Using
problems, sleep problems and spasticity can make alcohol as a pain medication can lead to alcohol pain worse or harder to treat. Keeping yourself as abuse and other serious problems. Some medi- healthy as possible can help reduce pain. cations should not be mixed with alcohol. Ask Try to get as much exercise as possible.
your doctor about drinking alcohol, and always Getting regular physical activity can reduce pain as well as improve mood and overall health. It can also be enjoyable and distract you from pain. Your health provider can help you choose physi- If you have pain, it is important to get treatment cal activities that are safe and appropriate for for it. The ideal source of help would be a physi- you. Also see the supplement “Activity Modifi -
cian and psychologist familiar with SCI and pain cation for Musculoskeletal Pain.”
Get treatment for depression. Depression
If you do not have easy access to such experts, the can make pain worse. It is best treated through next best alternative is to seek help from a multi- counseling and medication. Getting treatment disciplinary pain clinic where physicians and psy- for depression can help you cope with chronic chologists are available. Work closely with a health pain and improve your quality of life.
care provider with whom you are comfortable and Reduce stress. Stress can make pain worse
or make the pain harder to cope with. You can Chronic pain is not hopeless. Try not to become learn to manage stress through counseling and discouraged if one treatment doesn’t work, and learning techniques to help you reduce stress be open to trying a variety of different techniques. and tension, such as relaxation training, biofeed- While complete relief from pain may not be pos- back and hypnosis. Exercise helps reduce stress. sible, living better despite pain is a realistic goal.
Distract yourself. Distraction is one of the
best methods for coping with chronic pain. • Pain Connection, www.painconnection.org Participating in enjoyable and meaningful activi- • American Pain Society, www.ampainsoc.org ties can help reduce pain and help you feel more • American Pain Foundation, www.painfoundation.org in control of your life, especially when pain is at • CareCure Community Moderated Forums, including a pain forum. http://sci.rutgers.edu/forum/ its worst. When you are bored and inactive, you tend to focus more on your pain, and this can Our health information content is based on research evi-dence and/or professional consensus and has been reviewed Keep a record. Everyone’s pain is a little differ-
and approved by an editorial team of experts from the SCI ent. Keep a record of what makes you feel bet- ter and what makes pain worse. Understanding things that affect your pain will help you and your Pain after Spinal Cord Injury was developed by J. Scott Rich- doctor to fi nd effective ways to reduce your pain. Spinal Cord Injury Model Systems Consumer Information
ards, PhD, Trevor Dyson-Hudson, MD, Thomas N. Bryce, MD, Get a wheelchair seating evaluation. Poor
and Anthony Chiodo, MD, in collaboration with the Model Systems Knowledge Translation Center. posture and improper seating can cause serious pain problems. Get your seating evaluated by a Portions of this document were adapted from materials developed by the UAB SCI Model System, University of physical therapist who specializes in wheelchair Michigan Model SCI Care System, Northwest Regional SCI seating. If you use a manual wheelchair, try to get
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