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ORIGINAL ARTICLE
Pain after paraplegia: a survey in India
N Gupta
1
, J Solomon
2
and K Raja
2
1
Department of Physiotherapy, College of Applied Education and Health Sciences, Meerut, India and
2
Department of Physiotherapy,
Manipal College of Allied Health Sciences, Manipal, India
Study design: A postal survey.
Objective: To ascertain the incidence of pain in individuals with paraplegia in India and to associate
it with demographic characteristics.
Setting: India.
Method: The study was done by means of a questionnaire. This questionnaire was mailed to the
identified individuals (n¼600) on the addresses obtained from the medical records section of hospitals
and from various organizations. Data analysis was done by using non-parametric tests of association.
Results: The return rate was 46% (276/600). Fifty-seven percent of individuals complained of pain. Of
this, pain in the back and chest ranked the highest (30.1%), followed by pain below the level of lesion
(6.9%), pain in the shoulder and upper limb (4.7%) and neck (0.4%). Fifteen percent of individuals
complained of pain at multiple sites. We found a significant association of pain with age, duration since
injury and ambulation.
Conclusion: More than half of the subjects complained of pain in the study. Pain was found to be
associated with age, duration since injury and ambulation. As pain has a dramatic effect on a subjects’
quality of life, there is a need to evaluate it in detail and treat accordingly with preventive, rehabilitative
or surgical procedures.
Spinal Cord (2010) 48, 342–346; doi:10.1038/sc.2009.165; published online 15 December 2009
Keywords: pain; paraplegia; spinal cord injury; age; duration since injury; ambulation
Introduction
Pain is a significant problem encountered in individuals
with spinal cord injury (SCI). This pain often starts within
6 months of SCI and continues throughout life.
1
Incidence
of acute pain is 96%.
2
The estimated prevalence of chronic
pain varies from 11 to 94%
1
and in a recent study, it was
found to be 76%.
3
Studies have shown that almost all of the
patients (96%) experienced pain at some stage during their
inpatient rehabilitation.
2
There is a relationship between
pain reported in the acute phase (6 weeks after injury), and
pain reported 1 year after hospital discharge. A study by
Kennedy, Frankel, Gardener and Nuseibeh (1997) in UK
showed that within the acute category, 24% of respondents
(6 weeks after injury) reported very intense pain, whereas the
prevalence of chronic pain (at 1 year after hospital discharge)
was found to be 41%. A similar prevalence was also reported
by UmLauf (1987) and Britell and Mariano.
4
The most common locations of pain reported in literature
are the back (61%), hips and buttocks (61%) and legs and feet
(58%). Upper extremity pain was experienced by 76% of
subjects after the initial injury.
1
In the upper extremity, 71%
had shoulder pain, 53% wrist pain, 43% hand pain and 35%
elbow pain. Pain interfered with transfers in 65% of the
patients who were doing them. Pain was more likely to be
associated with pressure relief, transfers and wheelchair
mobility.
5
Wheelchair use has been a contributing factor to pain. Curtis
et al.
6
had reported a self-report survey where it was found that
more than two thirds of the sample reported shoulder pain
since beginning wheelchair use. In India, ambulation is usually
deferred in favour of wheelchair due to reasons of accessibility
and cost. Individuals with paraplegia either spend most of their
timeonawheelchairorinarecumbentpositionbecauseof
environmental constraints like inaccessible or small houses,
uneven terrain and so on. The type of wheelchair normally
used by the spinal cord injured population in India is a basic
transport wheelchair, which requires undue forces to be exerted
for self-propulsion.
Pain was significantly more common in less-educated
persons and individuals not employed or in school.
1
It was
found to be associated with age,
1
time since injury (linear
relationship)
3,7
but reports about association between pain
and the neurologic level of the SCI were contradictory.
1
Received 7 July 2009; revised 23 October 2009; accepted 1 November 2009;
published online 15 December 2009
Correspondence: N Gupta, Department of Physiotherapy, College of Applied
Education and Health Sciences, Gangotri, Roorkee Road, Meerut, UP 250001,
India.
E-mail: nals235@yahoo.co.in
Spinal Cord
(2010) 48, 342 –346
&
2010 International Spinal Cord Society All rights reserved 1362-4393/10
$
32.00
www.nature.com/sc
The existing literature suggests that pain, whether acute
or chronic, leads to loss of function, interferes with activities
of daily living and demands for assistance.
1
It sometimes had
such an impact that individuals with SCI were ready to trade
pain relief for loss of bladder, bowel or sexual function.
8
Pain hinders community reintegration of individuals with
SCI
9
and their productive life. A prospective co-relational
study, by Donnelly and Eng, in 2005, had shown that 86%
of individuals with an SCI reported pain at 6 months after
discharge, with 27% of these individuals reporting pain that
impacted on many or most activities. Pain impact and pain
intensity were related to community reintegration.
10
As there has been no structured nationwide study report-
ing this aspect in India, the prevalence of this problem
in India is unclear. There is a need to understand the effect
of demographics on pain, so that preventive measures can be
taken before its occurrence.
Thus, this study was an initial attempt to ascertain the
incidence of pain in individuals with paraplegia in India and
to associate it with demographic characteristics.
Materials and methods
A postal survey by means of a questionnaire was done from
1 August 2004 to 31 May 2006. Subjects included in the
study were individuals with paraplegia of any cause, either
gender with evidence of complete cord lesion and who were
18 years or older. Subjects included were community dwell-
ing as well as institutionalized individuals.
Procedure
Part I: Development of questionnaire and validation.We
developed a questionnaire in English, which was constructed
at the language level of third grade education. The question-
naire was evaluated for face validity by five physiotherapists.
Each of the physiotherapists had a minimum of 5 years
working experience with SCI, including community-based
work with this population. The suggestions put forth by the
evaluators were incorporated, and the revised questionnaire
was pilot tested on 10 SCI individuals for comprehensibility.
Changes suggested were incorporated and this version was
again pilot tested on five patients who had not participated
in the first pilot testing. The final version was translated into
Indian languages by means of parallel back translation
ensuring that the language level was maintained at the third
grade level in all languages.
The final versions of the questionnaire consisted of the
following three sections:
The first section included demographic and disease chara-
cteristics namely age, gender, education, occupation, level of
lesion, duration since injury and ambulation status. The
expected responses to this section were open ended except
ambulation status, which was dichotomous (walking/not
walking).
The second section consisted of questions regarding pain.
The instructions pertaining to pain consisted of presence/
absence as well as site of pain. The patient was asked to mark
pain if it was ‘bothersome’ or ‘frequently occurring’
or ‘periodic’. Intensity was not queried because of the
inherent problems associated with the use of visual analogue
scale, in terms of understandability.
11
It was assumed that if a
subject reported pain, it was a significant factor in the
subjects’ perception.
The third section consisted of details of employment
following the SCI. The responses to this section were
open ended.
Part II: Administration of questionnaire. Because of the
absence of a national database on SCI, addresses of potential
subjects were collected from hospitals and organizations and
associations dedicated to the SCI population. Addresses of
individuals living in 20 of 28 states in India were collected.
The questionnaire in English and the relevant regional
language was mailed to the identified individuals (n¼600).
The mail packet included a covering letter in English and the
regional language, clearly outlining the purpose of the
questionnaire, the subject’s option to participate or not
and the expected return date; the questionnaire itself with
instructions for completion and a reply paid self-addressed
envelope. One reminder was sent a week after the expected
date of reply had passed. Those subjects who did not respond
to the reminder were not contacted again.
Data analysis
Data were analysed using descriptives. Pain and its association
with demographic details were analysed using co-efficient
of associationFGoodman Kruskal Tau.
Results
Return rate
Of the 600 individuals, 276 responded to the mailed question-
naire, with a return rate of 46%.
Demographics
Demographic characteristics included in the study were age,
gender, education, etiology, level of lesion and duration
since injury.
Age (in years) was categorized into 9: 18–o25, 25–o30,
30–o35, 35–o40, 40–o50, 50–o60, 60–o70, 70–o80, 480.
Of the 276 participants, 53 (19.2%) were in the age group
of 18–o25 years, 53 (19.2%) in 40–o50 years, 49 (17.8%) in
25–o30 years, 41 (14.9%) in 35–o40 years, 38 (13.8%)
in 30–o35 years, 30 (10.9%) in 50–o60 years and one each
(0.4%) in 70–o80 and more than 80 years. In total, 233
subjects were men and 43 were women.
Education was categorized into seven categories: no edu-
cation, primary, secondary, higher secondary, graduation,
post-graduation and professional. In all, 148 subjects (53.6%)
belonged to secondary education category, 40 (14.5%)
subjects had higher secondary education, 23 (8.3%) subjects
were illiterate, 22 (8%) subjects were graduates, 19 (6.9%)
subjects were professionals, 19 subjects (6.9%) had primary
education and 5 (1.8%) subjects were post-graduates.
Etiology was categorized into six categories: fall from
a height, fall of an object, road traffic accident, sports
Pain after paraplegia
N Gupta et al
343
Spinal Cord
related, gun-shot injury and non-traumatic insult. Falls from
height was the leading cause for spinal cord insult (25%),
followed by road traffic accidents (17.4%), non-traumatic
insult (8.3%), fall of an object (6.5%), gun shot injuries
(4.3%) and sports related cause of an insult (0.7%). Thirty-
eight percent of individuals did not mention the cause for
injury.
Level of lesion was categorized into four categories: not
mentioned, upper thoracic, lower thoracic and lumbar. In
all, 166 subjects (60.1%) had the lesion at the lumbar level,
39 subjects (14.1%) at the upper thoracic level, 31 subjects
(11.2%) at the lower thoracic level and 40 subjects (14.5%)
did not mention about the level.
Duration since injury was categorized into 11 categories:
1–o7 months, 7–o12 months, 1–o2 years, 2–o3 years,
3–o4 years, 4–o5 years, 5–o10 years, 10–o15 years,
15–o20 years, 20–o25 years and 425 years. Of the 276
participants, most of the subjects (57, 20.7%) were 1–o6
months after injury and the least (6, 2.2%) were in 15–o20
years after injury period.
Pain characteristics
Incidence of pain. Fifty-seven percent of individuals com-
plained of pain. All subjects complained of ‘bothersome’
‘frequently occurring’ pain.
Site of pain. Out of the 57% of individuals who complained
of pain, pain in the back and chest ranked the highest
(30.1%), followed by pain below the level of lesion (6.9%),
pain in the shoulder and upper limb (4.7%) and neck (0.4%).
Fifteen percent of individuals complained of pain at multiple
sites. The incidence of pain relative to site is depicted
in Figure 1.
Site of pain relative to different levels of lesion. Site of pain
relative to different levels of lesions is shown in Figure 2.
Significant association of pain with demographics
The associations of pain with demographics that were
significant are shown in Table 1. We found significant
association of pain with age, duration since injury and
ambulation (Figures 3–5).
Discussion
Pain is one of the leading causes of morbidity in individuals
with paraplegia. More than half of the individuals in our
study complained of pain at various sites. Pain in the back
and chest were more common in the subjects with lumbar
lesion, which could be explained as the majority of the
subjects in our study had sustained lumbar lesions. However,
association between pain and neurological level of lesion
is contradictory. We did not find any significant association
between pain and level of lesion. Pain in the back and chest
was the leading site of pain at all levels. The most common
location for pain reported by Turner, Cardenas, Warms and
McClellan, in 2001, was the back. The reasons cited by them
were mechanical factors. They stated that such pain
problems may be helped by treatments such as activity
pacing, avoidance of prolonged activity in one position and
regular stretching, range of motion and exercise regimens,
tailored to individuals who use wheelchairs. Subjects with
paraplegia may experience shoulder and upper extremity
pain associated with overuse related to weight bearing
during wheelchair transfers and the demands of wheelchair
Pain
Shoulder and UL
Back and Chest
Neck
Below level
Others
Number of cases
100806040
20
0
Figure 1 Incidence of pain relative to site. UL, upper limb. Level of lesion
3210
Number of cases
120
100
80
60
40
20
0
Pain
Shoulder and
Upper limb
Back and Chest
Below level of
lesion
Neck
Others
No pain
Figure 2 Distribution of pain at different levels of injury. Level
of lesion categories: 0, not mentioned; 1, upper thoracic; 2, lower
thoracic and 3, lumbar. Distribution of pain at different levels of
injury: upper thoracic: back and chest4others4below level
of lesion4shoulder and upper limb; lower thoracic: back and
chest4below level of lesion4others4shoulder and upper limb;
lumbar: back and chest4others4below level of lesion4shoulder
and upper limb4neck.
Table 1 Association of pain with demographics
Morbidity Demographics Tau Significance
Pain Age 0.063 0.000
Duration since injury 0.071 0.000
Ambulation 0.028 0.000
Pain after paraplegia
N Gupta et al
344
Spinal Cord
propulsion. Neck pain is more likely to be common
in subjects with cervical injuries than with that of lumbar
injuries.
1
We found a significant association of pain with age,
duration since injury and ambulation. Pain was common
in the age group of 40–o50 years followed by 18–o25 years,
which could be explained as it followed the trend of age
distribution of subjects in the study. Pain in the back and
chest was seen in almost all the age groups, with it being the
most common among subjects in the age groups of 40–o50
years, 18–o25 years and 25–o30 years. Shoulder and upper
limb pain were more prevalent in the age group of 50–o60
years, which could be due to the ageing process and due to
the higher perception of pain by older individuals.
2,7,12,13
The existing literature supports the finding of association
of pain and age, with greater pain intensity being found to be
associated with older age.
7,12,13
The reason could be the
decrease in plasticity of the central nervous system with age,
as far as neurogenic pain is concerned, as well as overuse
of supra-lesional joints leading to osteo-articular pains.
14
Another factor could be psycho-social stresses.
10
Pain in the back and chest was seen in all the groups
especially in the group that were 1–o6 months after injury.
As stated earlier, the majority of subjects in the study fell into
this age group. Pain in the shoulder, which was common in
the group that were 1–o2 years after injury, could be due
to the reason that the majority of the subjects in this group
were ambulators. Ambulation in these patients involved use
of walking aids, which may have contributed to increase in
shoulder pain. This was also seen in the groups that were
10–o15 years and 20–o25 years after injury. The existing
literature supports the fact that there is an association
between age and pain, with pain often starting within the
first 6 months after injury and continuing throughout
life. Ambulators experienced less pain compared with
non-ambulators, though the frequency of shoulder pain
was more among the ambulators.
In our study, there were three groups of subjects:
(1) subjects who were living in the community, (2) subjects
who were living in the centers run by armed forces and
Age
98
76
54321
Number of cases
50
40
30
20
10
0
Pain
Shoulder and
Upper limb
Back and Chest
Below level of
lesion
Neck
Others
No pain
Figure 3 Distribution of pain at different age groups. Age
categories (in years): (1) 18–o25, (2) 25–o30, (3) 30–o35, (4)
35–o40, (5) 40–o50, (6) 50–o60, (7) 60–o70, (8) 70–o80 and
(9) 480. Distribution of pain at different age groups: (1) back and
chest4others4below level of lesion4shoulder and upper limb; (2)
back and chest4others4below level of lesion4shoulder and upper
limb; (3) back and chest4others4below level of lesion4shoulder
and upper limb; (4) back and chest4below level of lesion4others4
shoulder and upper limb; (5) others4back and chest4below level of
lesion4shoulder and upper limb and neck; (6) back and chest4
below level of lesion4others4shoulder and upper limb; (7)
others4back and chest; (8) others; (9) back and chest.
Duration since injury
11
10987654321
0
Number of cases
60
50
40
30
20
10
0
Pain
Below level of
lesion
Back and Chest
Shoulder and
Upper limb
Neck
Others
No pain
Figure 4 Distribution of pain based on duration since injury.
Duration since injury: 0, not mentioned; (1) 1–o6 months; (2)
7–o12 months; (3) 1–o2 years; (4) 2–o3 years; (5) 3–o4 years; (6)
4–o5 years; (7) 5–o10 years; (8) 10–o15 years; (9) 15–o20 years;
(10) 20–o25 years and (11) 425 years. Pain distribution in
descending order in all the groups: (1) back and chest4others4be-
low level of lesion4shoulder and upper limb; (2) back and
chest4others4below level of lesion, shoulder and upper limb; (3)
back and chest4below level of lesion4others4shoulder and upper
limb; (4) back and chest4others4below level of lesion; (5) back and
chest4others; (6) back and chest, others4shoulder and upper limb;
(7) back and chest, others and below level of lesion4shoulder and
upper limb; (8) others, below level of lesion4back and chest4
shoulder and upper limb; (9) others4below level of lesion, back and
chest; (10) others4shoulder and upper limb4back and chest4neck;
(11) back and chest4below level of lesion, shoulder and upper limb.
Ambulation
AmbulatorNon-ambulators
Number of cases
200
100
0
Pain
Shoulder and
Upper limb
Back and Chest
Below level of
lesion
Neck
Others
no
Figure 5 Distribution of pain based on ambulatory status. Non-
ambulators: back and chest4others4below level of lesion4
shoulder and upper limb. Ambulators: back and chest, below level
of lesion4others, shoulder and upper limb.
Pain after paraplegia
N Gupta et al
345
Spinal Cord
(3) subjects who were living in the specialized centers or
non-governmental organizations. Pain was the leading cause
of morbidity in all the groups, with the frequency being the
highest among the subjects living in the community. This
could be due to low educational status and lack of awareness,
which precluded them from seeking medical help; lack
of pre-discharge home-visits and lack of regular follow-ups.
Although these individuals were able to ambulate with
wheelchair, they tended to spend more time in bed due
to socio-cultural or environmental constraints as described
earlier.
Limitations
Intensity and variation of pain patterns were not considered
in the study because of the inherent difficulties associated
with evaluating these in a survey of individuals in the lower
educational status. Tetraplegic individuals were not sampled
for this study.
Implications
As pain was found to be the major morbidity among all the
groups, preventive measures should be taken from the
beginning such as:
(a) Regular change in patients’ position or avoidance
of prolonged activity in one position.
1
(b) Regular stretching and range of motion exercises for all
the joints as there is an association of pain with spasticity.
1
(c) Individual should be taught proper transfer techniques
to put less pressure on the shoulder joint. This is because
overuse related to weight transfers and wheelchair
propulsion could lead to pain in shoulder and upper
extremity.
1
(d) Seating posture must be taken into consideration for
pain relief in wheelchair users as they tend to sit in
a kyphotic posture to be stable in wheelchair propulsion
and other activities. This leads to forward and downward
movement of the scapula, depression of the acromion
processes and changing the facing of glenoid fossa, thus
posture must be evaluated.
15
(e) Wheelchair can be modified by changing the position
of axle as more forward axle position has been correlated
with improvement in wheelchair biomechanics.
16
(f) Propulsion technique with least energy expenditure can
be taught to the individual with paraplegia such
as semicircular propulsion technique. Semicircular pro-
pulsion technique displays characteristics consistent
with reduced repetitions and more efficient propulsion.
Use of this propulsion style may reduce trauma to the
upper extremities.
17
(g) And if still the pain persists, it should be assessed
and treated accordingly with modalities or surgical
measures. Individual’s pain should always be taken into
consideration and activities should be paced accordingly.
Conclusion
More than half of the subjects complained of pain in the
study. Pain was found to be associated with age, duration
since injury and ambulation. As pain has a dramatic effect on
a subjects’ quality of life, there is a need to evaluate it
in detail and treat accordingly with preventive, rehabilitative
or surgical procedures.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
This study was funded in part by Indian Association
of Physiotherapists (IAP).
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