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In New Zealand, the most recent figures for the mean annual incidence of traumatic spinal cord injuries (TSCI) over a 10-year period has been found to be 22 per million people.[[1]] This has decreased from the previously estimated rate of 49 per million from 1998; however, it is difficult to gauge where this new estimate lies in the global context, given the wide variability of figures.[[2,3]] From the New Zealand Spinal Cord Injury Registry (NZSCIR) Annual Report in 2020, it was reported that the incidence rate of TSCI and non-traumatic SCI (NTSCI) combined was 44 per million. Local studies have also shown disparities in the incidence of TSCI in New Zealand, with more people of Māori and Pacific Island ethnicities having higher rates of injuries compared to others.[[1,4]]

Among patients with spinal cord injuries (SCI), one of the most prevalent chronic complications is pain.[[5–7]] A systematic review and meta-analysis by Hunt et al. classified chronic pain post-SCI using the International Spinal Cord Injury Pain (ISCIP) classification, and reported neuropathic pain in 79% of patients, musculoskeletal pain in 58% and visceral pain in 3%.[[8]] Fifty four percent reported two or more types of pain. The pooled prevalence in this meta-analysis was 68%. Consequently, pain can hinder patients’ rehabilitation and their transition into community as it affects quality of sleep, ability to return to paid employment, mood and anxiety levels and social connectedness.[[9–12]]

Our study’s primary objective was to determine the proportion of patients who reported pain on discharge, with a particular focus on how pain impacted their activities of daily living (ADLs), mood and sleep. The secondary objectives were to assess their satisfaction with pain management, and the relationship between pain and patient demographics such as ethnicity, age, level of injury, severity of injury (The American Spinal Injury Association (ASIA) Impairment Scale) and type of SCI (TSCI vs NTSCI).

The outcomes of this study hope to guide future decisions in community programmes and rehabilitation systems that can be established to support patients with a SCI after discharge. It will also contribute to the way that pain is discussed prior to discharge so that patients and their whānau feel more equipped for the transition.

Method

This was a retrospective study that used data collected prospectively of patients who sustained either a TSCI or a NTSCI and were admitted to one of the two spinal rehabilitation units in New Zealand. The rehabilitation units in New Zealand are the Auckland Spinal Rehabilitation Unit (ASRU) and the Burwood Spinal Unit (BSU). The ASRU admits patients with SCI from approximately the upper half of the North Island, whereas the BSU admits patients from the region below. The data for this study was collated from the years 2018 to 2019 and obtained through the New Zealand Spinal Cord Injury Registry (NZSCIR) with access granted by the NZSCIR Data Access Group. The data received did not include any identifiable information. Ethics approval was obtained via the Auckland Health Research Ethics Committee (AHREC) (Reference number: AH23267). The study’s inclusion criteria focussed on adult patients above the age of 16 with a TSCI or a NTSCI who consented for a discharge interview at the time of their discharge from ASRU/BSU. The study’s exclusion criteria consisted of patients with incomplete data and/or those who declined consent to participate in the NZSCIR.

The data stored in the NZSCIR were obtained from discharge interviews with patients that were typically conducted prior to transition from their respective spinal rehabilitation unit to their discharge destination. The discharge interview is a questionnaire that asked patients to give a score from zero to 10 for questions relating to pain, its interference with ADLs, mood and sleep and their satisfaction with management for pain. Demographic characteristics including age, gender and ethnicity, as defined by the New Zealand Ministry of Health, were gathered on every participant in the NZSCIR as part of standard data collection. Ethnicity was classed as NZ European, Māori, Pasifika, and Others. Others included Asian, Middle Eastern, Latin American and African ethnicities. Information on neurological level of injury and completeness of injury were collected. The level of injury and severity noted were those recorded on discharge from the rehabilitation units. Where level of injury on discharge was not available, the level noted on admission to rehabilitation was used. The level of neurological injury was grouped into either tetraplegia/paraplegia/intact. The American Spinal Injury Association Impairment Scale (AIS) was used to describe the completeness of spinal cord injury. This ranges from “A”, representing a complete injury (no sensation or motor activity below the level of injury), to “E” (normal sensory and motor function).[[13]]

Questions in the discharge interview related to pain were:

• “Have you had any pain in the last 7 days, including today?”

• “Are you receiving treatment for a pain problem?”

• “If yes (to above), what treatments do you use to manage your pain?”

• “Overall, how satisfied are you with the management of your pain?”

• “In general, how much has pain interfered with your day-to-day activities in the last week?”

• “In general, how much has pain interfered with your overall mood in the last week?”

• “In general, how much has pain interfered with your ability to get a good night’s sleep?”

The Numerical Rating Scale (NRS) was used as the self-reported measure for the questions relating to pain management satisfaction and the level of interference with functionality. Numbers from zero to 10 were presented and answers recorded by coordinators interviewing the patients on discharge. A score of 10 was considered optimal pain management, a score between seven to nine was considered satisfactory management, and a score of zero was considered completely dissatisfied with management. A score of seven and above for the questions relating to functionality was considered “severe” interference, based on a study by Boonstra et al., who investigated the cut-off points for “severe” interference with chronic musculoskeletal pain.[[14]] A score of zero for the functionality questions thus indicated no interference. The scores provided by patients for each individual question were collated and a median score was found.

Based on the answers given for pain on discharge: “Yes” or “No”, the patients in each demographic/SCI characteristic group were stratified according to the answers given. The patients who answered “Yes” to pain on discharge were of focus to our study. Data were reported as frequency and proportions for patient characteristics and pain on discharge. Two by two contingency tables and Chi-squared or Fisher’s exact test were used to assess potential associations of pain on discharge rates by demographics/SCI characteristics. P-values of less than 5% were considered as statistically significant. All statistical analyses were carried out using OpenEpi and SAS version 9.4.

Results

View Figures & Tables.

In the years 2018 and 2019, 435 patients sustained a SCI in New Zealand (Figure 1). Three hundred and seventy-two of these patients were admitted to ASRU or BSU for rehabilitation. Two hundred ad seventy-four patients consented to discharge interviews being completed for the NZSCIR. Ninety-eight out of 372 eligible patients did not participate in this study, producing an attrition rate of 26.3%. Out of the 274 patients, 210 answered “Yes” to pain on discharge and 64 answered “No” (Table 1). The proportion of patients who reported pain on discharge from this study population was 76.6%.

The age group with the highest proportion of reported pain on discharge was the 46–60 years category (84%). One hundred and twenty-eight patients identified as NZ European, 47 as Māori, 23 as Pacific Island, and 12 as Others. Despite making up only 19% of the patients who consented for the discharge questionnaire, Māori patients had the most pain reported on discharge, with 88.7% reporting “Yes”. The Pacific Island group were second, with 76.7% reporting “Yes”. One hundred and forty-six were male and 64 were female, with more females reporting pain in proportion (82.1%). For those reporting pain on discharge, 145 patients sustained a TSCI and 65 sustained a NTSCI. 111 patients were tetraplegic, 96 were paraplegic and 3 were intact. AIS A was the level at which there were the greatest proportion of patients with pain on discharge (83.6%).

Overall, the median score for satisfaction of pain management in the total population was eight (Figure 2). Out of the 210 patients, 60 patients (28.6%) scored their satisfaction as optimal pain management with 10 out of 10. One hundred and three patients (49.0%) scored within the range of seven to nine, as satisfactory pain management. The median scores for effect of pain on interference with ADLs, mood, and sleep were all three out of 10 (Figures 3–5). With ADLs, 35/210 patients (16.7%) reported “severe” interference due to pain, whereas 55 (26.2%) reported no interference. Thirty-four out of two hundred and ten patients (16.2%) reported “severe” interference with their mood, and 64 (30.5%) denied any interference. Sleep was the functional task that showed the greatest number of patients reporting “severe” interference, with 50/210 patients (23.8%). However, 64 patients (30.5%) reported no interference with sleep. On further questioning, the mode of treatment for pain was largely dominated by pharmacological means (both prescription and non-prescription) in both the TSCI and NTSCI groups (Figures 6–7).

Discussion

The purpose of this study was to investigate the prevalence of pain and its impact on functionality (ADLs, mood and sleep) for patients with a SCI near their time of discharge. Pain after sustaining a SCI, whether traumatic or non-traumatic, is a common complication and the interference with ADLs, sleep, and mood are also well documented.[[5–12]] In our study, it was found that 210/274 patients (76.6%) reported having pain at time of discharge. This is consistent with other literatures’ statistics.[[6,7,15]] Despite the number of patients reporting pain being high, our study shows that the management for pain is still satisfactory for most, and interferences with ADLs, mood and sleep are low overall. The median scores for the level of interference with ADLs, mood and sleep were all three out of 10, implying that pain plays a small part in affecting the lives of majority of our patients. Almost 78% of patients reported at least a satisfactory management of their pain, with 28.6% reporting completely optimal management. This is a reassuring sign that current modalities for pain management are effective for most SCI patients in New Zealand at the time of discharge. However, further focus can be made to assess if pain management is maintained in the community with longer follow-up, considering that the ramifications of pain can change over time post-discharge.

In Norrbrink Budh’s study, pain was the major factor interfering with sleep quality, showing patients with continuous pain had poorer sleep than those with nil or intermittent pain.[[9]] They also noted that mood and sleep were interlinked, as patients with lower mood tended to have poorer sleep. Low mood was not reported to have improved significantly over the course of 10 years after sustaining a SCI; hence, Cruz-Almeida theorised that this long-term low mood also contributes to the chronic pain experienced by patients.[[16]] This bidirectional relationship between pain and mood also exists with pain and sleep as well, with pregabalin providing significant improvement in reducing pain-related interference with sleep.[[17–19]] In a study from 2001, approximately 40% of patients were found to have difficulty falling asleep or staying asleep due to pain,[[20]] whereas our study indicates that approximately a quarter of the patients report being severely affected (23.8%). Out of the 3 facets of functionality that were measured in our study, more patients reported “severe” interference with sleep, compared to interference with ADLs (16.7%) or mood (16.2%). However, it is reassuring to see that in our study there is consistently a greater proportion of patients reporting no interference for all ADLs, mood and sleep.

The principles of Te Tiriti o Waitangi stress the importance of upholding certain values for the healthcare of Māori: tino rangatiratanga, equity, active protection, options and partnership.[[21]] This should be held with high regard in SCI management based on the results seen from our study. Incidence rates of SCI were higher for Māori compared to other ethnic groups, which has not changed since the last study conducted on SCI in New Zealand.[[1]] In addition, our data implies Māori had the largest proportion of patients having pain on discharge compared to non-Māori. However, it should be noted that due to the limitation of this study having no individual data available through the Registry, we were unable to perform multi-variate analysis to deduce that ethnicity was a single contributing factor. Other studies have also shown that racial and ethnic minorities with SCI are more likely to have more health complications, low mood and poorer quality of life.[[22–24]]

There were limitations to our study. Firstly, the attrition rate of data loss was approximately 26% from the SCI patients who were admitted for rehabilitation. This was due to variety of reasons, including age (under 16 years), no consent for the full data set (e.g., non-residents, comorbidities preventing interviews or declining participation), or incomplete discharge interviews (due to death, transition to palliative care or transfer to another facility before completion of interview). The data in our study were all self-reported by the patients, which can allow the definition of “pain” being interpreted in different ways depending on the patient’s values, culture and life experience. This is seen in certain meta-analyses, where high heterogeneity has been reported across various studies that were used.[[6,7]] Hence, the prevalence reported in our study may not be entirely accurate. A cumulative dataset was provided by the Registry as opposed to individual patient information; hence, no further univariate or multivariate analyses could be performed to investigate significant factors for pain and interference with functionality. The questionnaire also did not include a question that quantified the actual severity of pain; hence analysis of this could not be attained.

Furthermore, our study has shown that while there are a significant proportion of patients with SCI leaving rehabilitation units with pain, there is high satisfaction with the management for this pain and low interference with functionality in day-to-day activities. Future focus will be to investigate ways of providing better community support for the small percentage of patients experiencing pain that interferes with their functionality. It is also crucial to further evaluate and mitigate the inequities seen in ethnic differences of pain prevalence.

Summary

Abstract

Aim

Pain is a common complication of spinal cord injuries (SCI).Our objective was to quantify those who had pain on discharge from rehabilitation,and the level of interference it had on their functionality.

Method

This study used data collected prospectively from 2018 to 2019 via the New Zealand Spinal Cord Injury Registry (NZSCIR). Questionnaires completed by patients on discharge provided the necessary data. Primary outcomes were the number of patients reporting pain, and the level of interference with their activities of daily living (ADLs), mood and sleep. Level of interference was quantified via a score from zero to 10. Scores of seven and above were considered “severe” interference.

Results

Seventy-six-point six percent of patients in this study group reported having pain on discharge. The median scores for interference with functionality were all three out of 10. Twenty-three-point eight percent of patients reported severe interference with sleep, 16.7% with ADLs and 16.2% with mood.

Conclusion

The number of patients being discharged with pain from SCI rehabilitation units in New Zealand is similar to figures from other literature. Although significant functional impairments were not found overall, focus remains to optimise management for patients who do report “severe” interference.

Author Information

Jae Hong Ryu: House Officer, Counties Manukau District Health Board, Auckland, New Zealand. Hannah Joyce: House Officer, Counties Manukau District Health Board, Auckland, New Zealand. Christin Coomarasamy: Biostatistician, Department of Biostatistics, Counties Manukau District Health Board, Auckland, New Zealand. Jessica Ozumba: New Zealand Spinal Cord Injury Registry Coordinator, Auckland Spinal Rehabilitation Unit, Counties Manukau District Health Board, Auckland, New Zealand. Victoriya Semikina: House Officer, Counties Manukau District Health Board Auckland, New Zealand. Suresh Subramanian: Spinal rehabilitation Senior Medical Officer, Auckland Spinal Rehabilitation Unit, Counties Manukau District Health Board, Auckland, New Zealand..

Acknowledgements

Correspondence

Jae Hong Ryu: House Officer, Counties Manukau District Health Board, Auckland, New Zealand.

Correspondence Email

jryu280@aucklanduni.ac.nz

Competing Interests

Nil.

1) Mitchell J, Nunnerley J, Frampton C et al. Epidemiology of traumatic spinal cord injury in New Zealand (2007–2016). N Z Med J. 2020;133(1509).

2) Dixon G, Danesh J, Caradoc-Davies T. Epidemiology of spinal cord injury in New Zealand. Neuroepidemiology. 1993;12(2):88-95.

3) Wyndaele M, Wyndaele J. Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord. 2006;44(9):523-529.

4) Derrett S, Beaver C, Sullivan MJ, et al. Traumatic and non-traumatic spinal cord impairment in New Zealand: incidence and characteristics of people admitted to spinal units. Inj Prev. 2012;18(5):343-346.

5) Mahnig S, Landmann G, Stockinger L, Opsommer E. Pain assessment according to the International Spinal Cord Injury Pain classification in patients with spinal cord injury referred to a multidisciplinary pain center. Spinal Cord. 2016;54(10):809-815.

6) Burke D, Fullen BM, Stokes D, Lennon O. Neuropathic pain prevalence following spinal cord injury: A systematic review and meta-analysis. Eur J Pain. 2016;21(1):29-44.

7) Warner F, Cragg J, Jutzeler C, et al. Progression of Neuropathic Pain after Acute Spinal Cord Injury: A Meta-Analysis and Framework for Clinical Trials. J Neurotrauma. 2019;36(9):1461-1468.

8) Hunt C, Moman R, Peterson A, et al. Prevalence of chronic pain after spinal cord injury: a systematic review and meta-analysis. Reg Anesth Pain Med. 2021;46(4):328-336.

9) Norrbrink Budh C, Hultling C, Lundeberg T. Quality of sleep in individuals with spinal cord injury: a comparison between patients with and without pain. Spinal Cord. 2004;43(2):85-95.

10) Sinnott A, Cassidy B, Nunnerley J, et al. Commentary on Community Participation Following Spinal Cord Injury in New Zealand. Top Spinal Cord Inj Rehabil. 2010;15(4):63-71.

11) Migliorini C, Tonge B, Taleporos G. Spinal Cord Injury and Mental Health. Aust N Z J Psychiatry. 2008;42(4):309-314.

12) Hilton G, Unsworth C, Murphy G. The experience of attempting to return to work following spinal cord injury: a systematic review of the qualitative literature. Disabil Rehabil. 2017;40(15):1745-1753.

13) International Standards for Neurological Classification of SCI (ISNCSCI) Worksheet - American Spinal Injury Association [Internet]. American Spinal Injury Association. 2019 [cited 18 April 2022]. Available from: https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/.

14) Boonstra A, Preuper H, Balk G, Stewart R. Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain. 2014;155(12):2545-2550.

15) Siddall P, McClelland J, Rutkowski S, Cousins M. A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury. Pain. 2003;103(3):249-257.

16) Cruz-Almeida Y, Alameda G, Widerström-Noga E. Differentiation between pain-related interference and interference caused by the functional impairments of spinal cord injury. Spinal Cord. 2008;47(5):390-395.

17) Smith M, Haythornthwaite J. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev. 2004;8(2):119-132.

18) Roehrs T. Does Effective Management of Sleep Disorders Improve Pain Symptoms? Drugs. 2009;69(Supplement 2):5-11.

19) Cardenas D, Emir B, Parsons B. Examining the Time to Therapeutic Effect of Pregabalin in Spinal Cord Injury Patients With Neuropathic Pain. Clin Ther. 2015;37(5):1081-1090.

20) Widerström-Noga E, Felipe-Cuervo E, Yezierski R. Chronic pain after spinal injury: Interference with sleep and daily activities. Arch Phys Med Rehabil. 2001;82(11):1571-1577.

21) Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry [Internet]. Wellington. 2019 [cited Apr 18 2022]. Available from: https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_152801817/Hauora%20W.pdf.

22) Krause J, Broderick L, Saladin L, Broyles J. Racial Disparities in Health Outcomes After Spinal Cord Injury: Mediating Effects of Education and Income. J Spinal Cord Med. 2006;29(1):17-25.

23) Krause J, Saladin L, Adkins R. Disparities in subjective well-being, participation, and health after spinal cord injury: A 6-year longitudinal study. NeuroRehabilitation. 2009;24(1):47-56.

24) Myaskovsky L, Burkitt K, Lichy A, et al. The Association of Race, Cultural Factors, and Health-Related Quality of Life in Persons With Spinal Cord Injury. Arch Phys Med Rehabil. 2011;92(3):441-448.

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In New Zealand, the most recent figures for the mean annual incidence of traumatic spinal cord injuries (TSCI) over a 10-year period has been found to be 22 per million people.[[1]] This has decreased from the previously estimated rate of 49 per million from 1998; however, it is difficult to gauge where this new estimate lies in the global context, given the wide variability of figures.[[2,3]] From the New Zealand Spinal Cord Injury Registry (NZSCIR) Annual Report in 2020, it was reported that the incidence rate of TSCI and non-traumatic SCI (NTSCI) combined was 44 per million. Local studies have also shown disparities in the incidence of TSCI in New Zealand, with more people of Māori and Pacific Island ethnicities having higher rates of injuries compared to others.[[1,4]]

Among patients with spinal cord injuries (SCI), one of the most prevalent chronic complications is pain.[[5–7]] A systematic review and meta-analysis by Hunt et al. classified chronic pain post-SCI using the International Spinal Cord Injury Pain (ISCIP) classification, and reported neuropathic pain in 79% of patients, musculoskeletal pain in 58% and visceral pain in 3%.[[8]] Fifty four percent reported two or more types of pain. The pooled prevalence in this meta-analysis was 68%. Consequently, pain can hinder patients’ rehabilitation and their transition into community as it affects quality of sleep, ability to return to paid employment, mood and anxiety levels and social connectedness.[[9–12]]

Our study’s primary objective was to determine the proportion of patients who reported pain on discharge, with a particular focus on how pain impacted their activities of daily living (ADLs), mood and sleep. The secondary objectives were to assess their satisfaction with pain management, and the relationship between pain and patient demographics such as ethnicity, age, level of injury, severity of injury (The American Spinal Injury Association (ASIA) Impairment Scale) and type of SCI (TSCI vs NTSCI).

The outcomes of this study hope to guide future decisions in community programmes and rehabilitation systems that can be established to support patients with a SCI after discharge. It will also contribute to the way that pain is discussed prior to discharge so that patients and their whānau feel more equipped for the transition.

Method

This was a retrospective study that used data collected prospectively of patients who sustained either a TSCI or a NTSCI and were admitted to one of the two spinal rehabilitation units in New Zealand. The rehabilitation units in New Zealand are the Auckland Spinal Rehabilitation Unit (ASRU) and the Burwood Spinal Unit (BSU). The ASRU admits patients with SCI from approximately the upper half of the North Island, whereas the BSU admits patients from the region below. The data for this study was collated from the years 2018 to 2019 and obtained through the New Zealand Spinal Cord Injury Registry (NZSCIR) with access granted by the NZSCIR Data Access Group. The data received did not include any identifiable information. Ethics approval was obtained via the Auckland Health Research Ethics Committee (AHREC) (Reference number: AH23267). The study’s inclusion criteria focussed on adult patients above the age of 16 with a TSCI or a NTSCI who consented for a discharge interview at the time of their discharge from ASRU/BSU. The study’s exclusion criteria consisted of patients with incomplete data and/or those who declined consent to participate in the NZSCIR.

The data stored in the NZSCIR were obtained from discharge interviews with patients that were typically conducted prior to transition from their respective spinal rehabilitation unit to their discharge destination. The discharge interview is a questionnaire that asked patients to give a score from zero to 10 for questions relating to pain, its interference with ADLs, mood and sleep and their satisfaction with management for pain. Demographic characteristics including age, gender and ethnicity, as defined by the New Zealand Ministry of Health, were gathered on every participant in the NZSCIR as part of standard data collection. Ethnicity was classed as NZ European, Māori, Pasifika, and Others. Others included Asian, Middle Eastern, Latin American and African ethnicities. Information on neurological level of injury and completeness of injury were collected. The level of injury and severity noted were those recorded on discharge from the rehabilitation units. Where level of injury on discharge was not available, the level noted on admission to rehabilitation was used. The level of neurological injury was grouped into either tetraplegia/paraplegia/intact. The American Spinal Injury Association Impairment Scale (AIS) was used to describe the completeness of spinal cord injury. This ranges from “A”, representing a complete injury (no sensation or motor activity below the level of injury), to “E” (normal sensory and motor function).[[13]]

Questions in the discharge interview related to pain were:

• “Have you had any pain in the last 7 days, including today?”

• “Are you receiving treatment for a pain problem?”

• “If yes (to above), what treatments do you use to manage your pain?”

• “Overall, how satisfied are you with the management of your pain?”

• “In general, how much has pain interfered with your day-to-day activities in the last week?”

• “In general, how much has pain interfered with your overall mood in the last week?”

• “In general, how much has pain interfered with your ability to get a good night’s sleep?”

The Numerical Rating Scale (NRS) was used as the self-reported measure for the questions relating to pain management satisfaction and the level of interference with functionality. Numbers from zero to 10 were presented and answers recorded by coordinators interviewing the patients on discharge. A score of 10 was considered optimal pain management, a score between seven to nine was considered satisfactory management, and a score of zero was considered completely dissatisfied with management. A score of seven and above for the questions relating to functionality was considered “severe” interference, based on a study by Boonstra et al., who investigated the cut-off points for “severe” interference with chronic musculoskeletal pain.[[14]] A score of zero for the functionality questions thus indicated no interference. The scores provided by patients for each individual question were collated and a median score was found.

Based on the answers given for pain on discharge: “Yes” or “No”, the patients in each demographic/SCI characteristic group were stratified according to the answers given. The patients who answered “Yes” to pain on discharge were of focus to our study. Data were reported as frequency and proportions for patient characteristics and pain on discharge. Two by two contingency tables and Chi-squared or Fisher’s exact test were used to assess potential associations of pain on discharge rates by demographics/SCI characteristics. P-values of less than 5% were considered as statistically significant. All statistical analyses were carried out using OpenEpi and SAS version 9.4.

Results

View Figures & Tables.

In the years 2018 and 2019, 435 patients sustained a SCI in New Zealand (Figure 1). Three hundred and seventy-two of these patients were admitted to ASRU or BSU for rehabilitation. Two hundred ad seventy-four patients consented to discharge interviews being completed for the NZSCIR. Ninety-eight out of 372 eligible patients did not participate in this study, producing an attrition rate of 26.3%. Out of the 274 patients, 210 answered “Yes” to pain on discharge and 64 answered “No” (Table 1). The proportion of patients who reported pain on discharge from this study population was 76.6%.

The age group with the highest proportion of reported pain on discharge was the 46–60 years category (84%). One hundred and twenty-eight patients identified as NZ European, 47 as Māori, 23 as Pacific Island, and 12 as Others. Despite making up only 19% of the patients who consented for the discharge questionnaire, Māori patients had the most pain reported on discharge, with 88.7% reporting “Yes”. The Pacific Island group were second, with 76.7% reporting “Yes”. One hundred and forty-six were male and 64 were female, with more females reporting pain in proportion (82.1%). For those reporting pain on discharge, 145 patients sustained a TSCI and 65 sustained a NTSCI. 111 patients were tetraplegic, 96 were paraplegic and 3 were intact. AIS A was the level at which there were the greatest proportion of patients with pain on discharge (83.6%).

Overall, the median score for satisfaction of pain management in the total population was eight (Figure 2). Out of the 210 patients, 60 patients (28.6%) scored their satisfaction as optimal pain management with 10 out of 10. One hundred and three patients (49.0%) scored within the range of seven to nine, as satisfactory pain management. The median scores for effect of pain on interference with ADLs, mood, and sleep were all three out of 10 (Figures 3–5). With ADLs, 35/210 patients (16.7%) reported “severe” interference due to pain, whereas 55 (26.2%) reported no interference. Thirty-four out of two hundred and ten patients (16.2%) reported “severe” interference with their mood, and 64 (30.5%) denied any interference. Sleep was the functional task that showed the greatest number of patients reporting “severe” interference, with 50/210 patients (23.8%). However, 64 patients (30.5%) reported no interference with sleep. On further questioning, the mode of treatment for pain was largely dominated by pharmacological means (both prescription and non-prescription) in both the TSCI and NTSCI groups (Figures 6–7).

Discussion

The purpose of this study was to investigate the prevalence of pain and its impact on functionality (ADLs, mood and sleep) for patients with a SCI near their time of discharge. Pain after sustaining a SCI, whether traumatic or non-traumatic, is a common complication and the interference with ADLs, sleep, and mood are also well documented.[[5–12]] In our study, it was found that 210/274 patients (76.6%) reported having pain at time of discharge. This is consistent with other literatures’ statistics.[[6,7,15]] Despite the number of patients reporting pain being high, our study shows that the management for pain is still satisfactory for most, and interferences with ADLs, mood and sleep are low overall. The median scores for the level of interference with ADLs, mood and sleep were all three out of 10, implying that pain plays a small part in affecting the lives of majority of our patients. Almost 78% of patients reported at least a satisfactory management of their pain, with 28.6% reporting completely optimal management. This is a reassuring sign that current modalities for pain management are effective for most SCI patients in New Zealand at the time of discharge. However, further focus can be made to assess if pain management is maintained in the community with longer follow-up, considering that the ramifications of pain can change over time post-discharge.

In Norrbrink Budh’s study, pain was the major factor interfering with sleep quality, showing patients with continuous pain had poorer sleep than those with nil or intermittent pain.[[9]] They also noted that mood and sleep were interlinked, as patients with lower mood tended to have poorer sleep. Low mood was not reported to have improved significantly over the course of 10 years after sustaining a SCI; hence, Cruz-Almeida theorised that this long-term low mood also contributes to the chronic pain experienced by patients.[[16]] This bidirectional relationship between pain and mood also exists with pain and sleep as well, with pregabalin providing significant improvement in reducing pain-related interference with sleep.[[17–19]] In a study from 2001, approximately 40% of patients were found to have difficulty falling asleep or staying asleep due to pain,[[20]] whereas our study indicates that approximately a quarter of the patients report being severely affected (23.8%). Out of the 3 facets of functionality that were measured in our study, more patients reported “severe” interference with sleep, compared to interference with ADLs (16.7%) or mood (16.2%). However, it is reassuring to see that in our study there is consistently a greater proportion of patients reporting no interference for all ADLs, mood and sleep.

The principles of Te Tiriti o Waitangi stress the importance of upholding certain values for the healthcare of Māori: tino rangatiratanga, equity, active protection, options and partnership.[[21]] This should be held with high regard in SCI management based on the results seen from our study. Incidence rates of SCI were higher for Māori compared to other ethnic groups, which has not changed since the last study conducted on SCI in New Zealand.[[1]] In addition, our data implies Māori had the largest proportion of patients having pain on discharge compared to non-Māori. However, it should be noted that due to the limitation of this study having no individual data available through the Registry, we were unable to perform multi-variate analysis to deduce that ethnicity was a single contributing factor. Other studies have also shown that racial and ethnic minorities with SCI are more likely to have more health complications, low mood and poorer quality of life.[[22–24]]

There were limitations to our study. Firstly, the attrition rate of data loss was approximately 26% from the SCI patients who were admitted for rehabilitation. This was due to variety of reasons, including age (under 16 years), no consent for the full data set (e.g., non-residents, comorbidities preventing interviews or declining participation), or incomplete discharge interviews (due to death, transition to palliative care or transfer to another facility before completion of interview). The data in our study were all self-reported by the patients, which can allow the definition of “pain” being interpreted in different ways depending on the patient’s values, culture and life experience. This is seen in certain meta-analyses, where high heterogeneity has been reported across various studies that were used.[[6,7]] Hence, the prevalence reported in our study may not be entirely accurate. A cumulative dataset was provided by the Registry as opposed to individual patient information; hence, no further univariate or multivariate analyses could be performed to investigate significant factors for pain and interference with functionality. The questionnaire also did not include a question that quantified the actual severity of pain; hence analysis of this could not be attained.

Furthermore, our study has shown that while there are a significant proportion of patients with SCI leaving rehabilitation units with pain, there is high satisfaction with the management for this pain and low interference with functionality in day-to-day activities. Future focus will be to investigate ways of providing better community support for the small percentage of patients experiencing pain that interferes with their functionality. It is also crucial to further evaluate and mitigate the inequities seen in ethnic differences of pain prevalence.

Summary

Abstract

Aim

Pain is a common complication of spinal cord injuries (SCI).Our objective was to quantify those who had pain on discharge from rehabilitation,and the level of interference it had on their functionality.

Method

This study used data collected prospectively from 2018 to 2019 via the New Zealand Spinal Cord Injury Registry (NZSCIR). Questionnaires completed by patients on discharge provided the necessary data. Primary outcomes were the number of patients reporting pain, and the level of interference with their activities of daily living (ADLs), mood and sleep. Level of interference was quantified via a score from zero to 10. Scores of seven and above were considered “severe” interference.

Results

Seventy-six-point six percent of patients in this study group reported having pain on discharge. The median scores for interference with functionality were all three out of 10. Twenty-three-point eight percent of patients reported severe interference with sleep, 16.7% with ADLs and 16.2% with mood.

Conclusion

The number of patients being discharged with pain from SCI rehabilitation units in New Zealand is similar to figures from other literature. Although significant functional impairments were not found overall, focus remains to optimise management for patients who do report “severe” interference.

Author Information

Jae Hong Ryu: House Officer, Counties Manukau District Health Board, Auckland, New Zealand. Hannah Joyce: House Officer, Counties Manukau District Health Board, Auckland, New Zealand. Christin Coomarasamy: Biostatistician, Department of Biostatistics, Counties Manukau District Health Board, Auckland, New Zealand. Jessica Ozumba: New Zealand Spinal Cord Injury Registry Coordinator, Auckland Spinal Rehabilitation Unit, Counties Manukau District Health Board, Auckland, New Zealand. Victoriya Semikina: House Officer, Counties Manukau District Health Board Auckland, New Zealand. Suresh Subramanian: Spinal rehabilitation Senior Medical Officer, Auckland Spinal Rehabilitation Unit, Counties Manukau District Health Board, Auckland, New Zealand..

Acknowledgements

Correspondence

Jae Hong Ryu: House Officer, Counties Manukau District Health Board, Auckland, New Zealand.

Correspondence Email

jryu280@aucklanduni.ac.nz

Competing Interests

Nil.

1) Mitchell J, Nunnerley J, Frampton C et al. Epidemiology of traumatic spinal cord injury in New Zealand (2007–2016). N Z Med J. 2020;133(1509).

2) Dixon G, Danesh J, Caradoc-Davies T. Epidemiology of spinal cord injury in New Zealand. Neuroepidemiology. 1993;12(2):88-95.

3) Wyndaele M, Wyndaele J. Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord. 2006;44(9):523-529.

4) Derrett S, Beaver C, Sullivan MJ, et al. Traumatic and non-traumatic spinal cord impairment in New Zealand: incidence and characteristics of people admitted to spinal units. Inj Prev. 2012;18(5):343-346.

5) Mahnig S, Landmann G, Stockinger L, Opsommer E. Pain assessment according to the International Spinal Cord Injury Pain classification in patients with spinal cord injury referred to a multidisciplinary pain center. Spinal Cord. 2016;54(10):809-815.

6) Burke D, Fullen BM, Stokes D, Lennon O. Neuropathic pain prevalence following spinal cord injury: A systematic review and meta-analysis. Eur J Pain. 2016;21(1):29-44.

7) Warner F, Cragg J, Jutzeler C, et al. Progression of Neuropathic Pain after Acute Spinal Cord Injury: A Meta-Analysis and Framework for Clinical Trials. J Neurotrauma. 2019;36(9):1461-1468.

8) Hunt C, Moman R, Peterson A, et al. Prevalence of chronic pain after spinal cord injury: a systematic review and meta-analysis. Reg Anesth Pain Med. 2021;46(4):328-336.

9) Norrbrink Budh C, Hultling C, Lundeberg T. Quality of sleep in individuals with spinal cord injury: a comparison between patients with and without pain. Spinal Cord. 2004;43(2):85-95.

10) Sinnott A, Cassidy B, Nunnerley J, et al. Commentary on Community Participation Following Spinal Cord Injury in New Zealand. Top Spinal Cord Inj Rehabil. 2010;15(4):63-71.

11) Migliorini C, Tonge B, Taleporos G. Spinal Cord Injury and Mental Health. Aust N Z J Psychiatry. 2008;42(4):309-314.

12) Hilton G, Unsworth C, Murphy G. The experience of attempting to return to work following spinal cord injury: a systematic review of the qualitative literature. Disabil Rehabil. 2017;40(15):1745-1753.

13) International Standards for Neurological Classification of SCI (ISNCSCI) Worksheet - American Spinal Injury Association [Internet]. American Spinal Injury Association. 2019 [cited 18 April 2022]. Available from: https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/.

14) Boonstra A, Preuper H, Balk G, Stewart R. Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain. 2014;155(12):2545-2550.

15) Siddall P, McClelland J, Rutkowski S, Cousins M. A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury. Pain. 2003;103(3):249-257.

16) Cruz-Almeida Y, Alameda G, Widerström-Noga E. Differentiation between pain-related interference and interference caused by the functional impairments of spinal cord injury. Spinal Cord. 2008;47(5):390-395.

17) Smith M, Haythornthwaite J. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev. 2004;8(2):119-132.

18) Roehrs T. Does Effective Management of Sleep Disorders Improve Pain Symptoms? Drugs. 2009;69(Supplement 2):5-11.

19) Cardenas D, Emir B, Parsons B. Examining the Time to Therapeutic Effect of Pregabalin in Spinal Cord Injury Patients With Neuropathic Pain. Clin Ther. 2015;37(5):1081-1090.

20) Widerström-Noga E, Felipe-Cuervo E, Yezierski R. Chronic pain after spinal injury: Interference with sleep and daily activities. Arch Phys Med Rehabil. 2001;82(11):1571-1577.

21) Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry [Internet]. Wellington. 2019 [cited Apr 18 2022]. Available from: https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_152801817/Hauora%20W.pdf.

22) Krause J, Broderick L, Saladin L, Broyles J. Racial Disparities in Health Outcomes After Spinal Cord Injury: Mediating Effects of Education and Income. J Spinal Cord Med. 2006;29(1):17-25.

23) Krause J, Saladin L, Adkins R. Disparities in subjective well-being, participation, and health after spinal cord injury: A 6-year longitudinal study. NeuroRehabilitation. 2009;24(1):47-56.

24) Myaskovsky L, Burkitt K, Lichy A, et al. The Association of Race, Cultural Factors, and Health-Related Quality of Life in Persons With Spinal Cord Injury. Arch Phys Med Rehabil. 2011;92(3):441-448.

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In New Zealand, the most recent figures for the mean annual incidence of traumatic spinal cord injuries (TSCI) over a 10-year period has been found to be 22 per million people.[[1]] This has decreased from the previously estimated rate of 49 per million from 1998; however, it is difficult to gauge where this new estimate lies in the global context, given the wide variability of figures.[[2,3]] From the New Zealand Spinal Cord Injury Registry (NZSCIR) Annual Report in 2020, it was reported that the incidence rate of TSCI and non-traumatic SCI (NTSCI) combined was 44 per million. Local studies have also shown disparities in the incidence of TSCI in New Zealand, with more people of Māori and Pacific Island ethnicities having higher rates of injuries compared to others.[[1,4]]

Among patients with spinal cord injuries (SCI), one of the most prevalent chronic complications is pain.[[5–7]] A systematic review and meta-analysis by Hunt et al. classified chronic pain post-SCI using the International Spinal Cord Injury Pain (ISCIP) classification, and reported neuropathic pain in 79% of patients, musculoskeletal pain in 58% and visceral pain in 3%.[[8]] Fifty four percent reported two or more types of pain. The pooled prevalence in this meta-analysis was 68%. Consequently, pain can hinder patients’ rehabilitation and their transition into community as it affects quality of sleep, ability to return to paid employment, mood and anxiety levels and social connectedness.[[9–12]]

Our study’s primary objective was to determine the proportion of patients who reported pain on discharge, with a particular focus on how pain impacted their activities of daily living (ADLs), mood and sleep. The secondary objectives were to assess their satisfaction with pain management, and the relationship between pain and patient demographics such as ethnicity, age, level of injury, severity of injury (The American Spinal Injury Association (ASIA) Impairment Scale) and type of SCI (TSCI vs NTSCI).

The outcomes of this study hope to guide future decisions in community programmes and rehabilitation systems that can be established to support patients with a SCI after discharge. It will also contribute to the way that pain is discussed prior to discharge so that patients and their whānau feel more equipped for the transition.

Method

This was a retrospective study that used data collected prospectively of patients who sustained either a TSCI or a NTSCI and were admitted to one of the two spinal rehabilitation units in New Zealand. The rehabilitation units in New Zealand are the Auckland Spinal Rehabilitation Unit (ASRU) and the Burwood Spinal Unit (BSU). The ASRU admits patients with SCI from approximately the upper half of the North Island, whereas the BSU admits patients from the region below. The data for this study was collated from the years 2018 to 2019 and obtained through the New Zealand Spinal Cord Injury Registry (NZSCIR) with access granted by the NZSCIR Data Access Group. The data received did not include any identifiable information. Ethics approval was obtained via the Auckland Health Research Ethics Committee (AHREC) (Reference number: AH23267). The study’s inclusion criteria focussed on adult patients above the age of 16 with a TSCI or a NTSCI who consented for a discharge interview at the time of their discharge from ASRU/BSU. The study’s exclusion criteria consisted of patients with incomplete data and/or those who declined consent to participate in the NZSCIR.

The data stored in the NZSCIR were obtained from discharge interviews with patients that were typically conducted prior to transition from their respective spinal rehabilitation unit to their discharge destination. The discharge interview is a questionnaire that asked patients to give a score from zero to 10 for questions relating to pain, its interference with ADLs, mood and sleep and their satisfaction with management for pain. Demographic characteristics including age, gender and ethnicity, as defined by the New Zealand Ministry of Health, were gathered on every participant in the NZSCIR as part of standard data collection. Ethnicity was classed as NZ European, Māori, Pasifika, and Others. Others included Asian, Middle Eastern, Latin American and African ethnicities. Information on neurological level of injury and completeness of injury were collected. The level of injury and severity noted were those recorded on discharge from the rehabilitation units. Where level of injury on discharge was not available, the level noted on admission to rehabilitation was used. The level of neurological injury was grouped into either tetraplegia/paraplegia/intact. The American Spinal Injury Association Impairment Scale (AIS) was used to describe the completeness of spinal cord injury. This ranges from “A”, representing a complete injury (no sensation or motor activity below the level of injury), to “E” (normal sensory and motor function).[[13]]

Questions in the discharge interview related to pain were:

• “Have you had any pain in the last 7 days, including today?”

• “Are you receiving treatment for a pain problem?”

• “If yes (to above), what treatments do you use to manage your pain?”

• “Overall, how satisfied are you with the management of your pain?”

• “In general, how much has pain interfered with your day-to-day activities in the last week?”

• “In general, how much has pain interfered with your overall mood in the last week?”

• “In general, how much has pain interfered with your ability to get a good night’s sleep?”

The Numerical Rating Scale (NRS) was used as the self-reported measure for the questions relating to pain management satisfaction and the level of interference with functionality. Numbers from zero to 10 were presented and answers recorded by coordinators interviewing the patients on discharge. A score of 10 was considered optimal pain management, a score between seven to nine was considered satisfactory management, and a score of zero was considered completely dissatisfied with management. A score of seven and above for the questions relating to functionality was considered “severe” interference, based on a study by Boonstra et al., who investigated the cut-off points for “severe” interference with chronic musculoskeletal pain.[[14]] A score of zero for the functionality questions thus indicated no interference. The scores provided by patients for each individual question were collated and a median score was found.

Based on the answers given for pain on discharge: “Yes” or “No”, the patients in each demographic/SCI characteristic group were stratified according to the answers given. The patients who answered “Yes” to pain on discharge were of focus to our study. Data were reported as frequency and proportions for patient characteristics and pain on discharge. Two by two contingency tables and Chi-squared or Fisher’s exact test were used to assess potential associations of pain on discharge rates by demographics/SCI characteristics. P-values of less than 5% were considered as statistically significant. All statistical analyses were carried out using OpenEpi and SAS version 9.4.

Results

View Figures & Tables.

In the years 2018 and 2019, 435 patients sustained a SCI in New Zealand (Figure 1). Three hundred and seventy-two of these patients were admitted to ASRU or BSU for rehabilitation. Two hundred ad seventy-four patients consented to discharge interviews being completed for the NZSCIR. Ninety-eight out of 372 eligible patients did not participate in this study, producing an attrition rate of 26.3%. Out of the 274 patients, 210 answered “Yes” to pain on discharge and 64 answered “No” (Table 1). The proportion of patients who reported pain on discharge from this study population was 76.6%.

The age group with the highest proportion of reported pain on discharge was the 46–60 years category (84%). One hundred and twenty-eight patients identified as NZ European, 47 as Māori, 23 as Pacific Island, and 12 as Others. Despite making up only 19% of the patients who consented for the discharge questionnaire, Māori patients had the most pain reported on discharge, with 88.7% reporting “Yes”. The Pacific Island group were second, with 76.7% reporting “Yes”. One hundred and forty-six were male and 64 were female, with more females reporting pain in proportion (82.1%). For those reporting pain on discharge, 145 patients sustained a TSCI and 65 sustained a NTSCI. 111 patients were tetraplegic, 96 were paraplegic and 3 were intact. AIS A was the level at which there were the greatest proportion of patients with pain on discharge (83.6%).

Overall, the median score for satisfaction of pain management in the total population was eight (Figure 2). Out of the 210 patients, 60 patients (28.6%) scored their satisfaction as optimal pain management with 10 out of 10. One hundred and three patients (49.0%) scored within the range of seven to nine, as satisfactory pain management. The median scores for effect of pain on interference with ADLs, mood, and sleep were all three out of 10 (Figures 3–5). With ADLs, 35/210 patients (16.7%) reported “severe” interference due to pain, whereas 55 (26.2%) reported no interference. Thirty-four out of two hundred and ten patients (16.2%) reported “severe” interference with their mood, and 64 (30.5%) denied any interference. Sleep was the functional task that showed the greatest number of patients reporting “severe” interference, with 50/210 patients (23.8%). However, 64 patients (30.5%) reported no interference with sleep. On further questioning, the mode of treatment for pain was largely dominated by pharmacological means (both prescription and non-prescription) in both the TSCI and NTSCI groups (Figures 6–7).

Discussion

The purpose of this study was to investigate the prevalence of pain and its impact on functionality (ADLs, mood and sleep) for patients with a SCI near their time of discharge. Pain after sustaining a SCI, whether traumatic or non-traumatic, is a common complication and the interference with ADLs, sleep, and mood are also well documented.[[5–12]] In our study, it was found that 210/274 patients (76.6%) reported having pain at time of discharge. This is consistent with other literatures’ statistics.[[6,7,15]] Despite the number of patients reporting pain being high, our study shows that the management for pain is still satisfactory for most, and interferences with ADLs, mood and sleep are low overall. The median scores for the level of interference with ADLs, mood and sleep were all three out of 10, implying that pain plays a small part in affecting the lives of majority of our patients. Almost 78% of patients reported at least a satisfactory management of their pain, with 28.6% reporting completely optimal management. This is a reassuring sign that current modalities for pain management are effective for most SCI patients in New Zealand at the time of discharge. However, further focus can be made to assess if pain management is maintained in the community with longer follow-up, considering that the ramifications of pain can change over time post-discharge.

In Norrbrink Budh’s study, pain was the major factor interfering with sleep quality, showing patients with continuous pain had poorer sleep than those with nil or intermittent pain.[[9]] They also noted that mood and sleep were interlinked, as patients with lower mood tended to have poorer sleep. Low mood was not reported to have improved significantly over the course of 10 years after sustaining a SCI; hence, Cruz-Almeida theorised that this long-term low mood also contributes to the chronic pain experienced by patients.[[16]] This bidirectional relationship between pain and mood also exists with pain and sleep as well, with pregabalin providing significant improvement in reducing pain-related interference with sleep.[[17–19]] In a study from 2001, approximately 40% of patients were found to have difficulty falling asleep or staying asleep due to pain,[[20]] whereas our study indicates that approximately a quarter of the patients report being severely affected (23.8%). Out of the 3 facets of functionality that were measured in our study, more patients reported “severe” interference with sleep, compared to interference with ADLs (16.7%) or mood (16.2%). However, it is reassuring to see that in our study there is consistently a greater proportion of patients reporting no interference for all ADLs, mood and sleep.

The principles of Te Tiriti o Waitangi stress the importance of upholding certain values for the healthcare of Māori: tino rangatiratanga, equity, active protection, options and partnership.[[21]] This should be held with high regard in SCI management based on the results seen from our study. Incidence rates of SCI were higher for Māori compared to other ethnic groups, which has not changed since the last study conducted on SCI in New Zealand.[[1]] In addition, our data implies Māori had the largest proportion of patients having pain on discharge compared to non-Māori. However, it should be noted that due to the limitation of this study having no individual data available through the Registry, we were unable to perform multi-variate analysis to deduce that ethnicity was a single contributing factor. Other studies have also shown that racial and ethnic minorities with SCI are more likely to have more health complications, low mood and poorer quality of life.[[22–24]]

There were limitations to our study. Firstly, the attrition rate of data loss was approximately 26% from the SCI patients who were admitted for rehabilitation. This was due to variety of reasons, including age (under 16 years), no consent for the full data set (e.g., non-residents, comorbidities preventing interviews or declining participation), or incomplete discharge interviews (due to death, transition to palliative care or transfer to another facility before completion of interview). The data in our study were all self-reported by the patients, which can allow the definition of “pain” being interpreted in different ways depending on the patient’s values, culture and life experience. This is seen in certain meta-analyses, where high heterogeneity has been reported across various studies that were used.[[6,7]] Hence, the prevalence reported in our study may not be entirely accurate. A cumulative dataset was provided by the Registry as opposed to individual patient information; hence, no further univariate or multivariate analyses could be performed to investigate significant factors for pain and interference with functionality. The questionnaire also did not include a question that quantified the actual severity of pain; hence analysis of this could not be attained.

Furthermore, our study has shown that while there are a significant proportion of patients with SCI leaving rehabilitation units with pain, there is high satisfaction with the management for this pain and low interference with functionality in day-to-day activities. Future focus will be to investigate ways of providing better community support for the small percentage of patients experiencing pain that interferes with their functionality. It is also crucial to further evaluate and mitigate the inequities seen in ethnic differences of pain prevalence.

Summary

Abstract

Aim

Pain is a common complication of spinal cord injuries (SCI).Our objective was to quantify those who had pain on discharge from rehabilitation,and the level of interference it had on their functionality.

Method

This study used data collected prospectively from 2018 to 2019 via the New Zealand Spinal Cord Injury Registry (NZSCIR). Questionnaires completed by patients on discharge provided the necessary data. Primary outcomes were the number of patients reporting pain, and the level of interference with their activities of daily living (ADLs), mood and sleep. Level of interference was quantified via a score from zero to 10. Scores of seven and above were considered “severe” interference.

Results

Seventy-six-point six percent of patients in this study group reported having pain on discharge. The median scores for interference with functionality were all three out of 10. Twenty-three-point eight percent of patients reported severe interference with sleep, 16.7% with ADLs and 16.2% with mood.

Conclusion

The number of patients being discharged with pain from SCI rehabilitation units in New Zealand is similar to figures from other literature. Although significant functional impairments were not found overall, focus remains to optimise management for patients who do report “severe” interference.

Author Information

Jae Hong Ryu: House Officer, Counties Manukau District Health Board, Auckland, New Zealand. Hannah Joyce: House Officer, Counties Manukau District Health Board, Auckland, New Zealand. Christin Coomarasamy: Biostatistician, Department of Biostatistics, Counties Manukau District Health Board, Auckland, New Zealand. Jessica Ozumba: New Zealand Spinal Cord Injury Registry Coordinator, Auckland Spinal Rehabilitation Unit, Counties Manukau District Health Board, Auckland, New Zealand. Victoriya Semikina: House Officer, Counties Manukau District Health Board Auckland, New Zealand. Suresh Subramanian: Spinal rehabilitation Senior Medical Officer, Auckland Spinal Rehabilitation Unit, Counties Manukau District Health Board, Auckland, New Zealand..

Acknowledgements

Correspondence

Jae Hong Ryu: House Officer, Counties Manukau District Health Board, Auckland, New Zealand.

Correspondence Email

jryu280@aucklanduni.ac.nz

Competing Interests

Nil.

1) Mitchell J, Nunnerley J, Frampton C et al. Epidemiology of traumatic spinal cord injury in New Zealand (2007–2016). N Z Med J. 2020;133(1509).

2) Dixon G, Danesh J, Caradoc-Davies T. Epidemiology of spinal cord injury in New Zealand. Neuroepidemiology. 1993;12(2):88-95.

3) Wyndaele M, Wyndaele J. Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord. 2006;44(9):523-529.

4) Derrett S, Beaver C, Sullivan MJ, et al. Traumatic and non-traumatic spinal cord impairment in New Zealand: incidence and characteristics of people admitted to spinal units. Inj Prev. 2012;18(5):343-346.

5) Mahnig S, Landmann G, Stockinger L, Opsommer E. Pain assessment according to the International Spinal Cord Injury Pain classification in patients with spinal cord injury referred to a multidisciplinary pain center. Spinal Cord. 2016;54(10):809-815.

6) Burke D, Fullen BM, Stokes D, Lennon O. Neuropathic pain prevalence following spinal cord injury: A systematic review and meta-analysis. Eur J Pain. 2016;21(1):29-44.

7) Warner F, Cragg J, Jutzeler C, et al. Progression of Neuropathic Pain after Acute Spinal Cord Injury: A Meta-Analysis and Framework for Clinical Trials. J Neurotrauma. 2019;36(9):1461-1468.

8) Hunt C, Moman R, Peterson A, et al. Prevalence of chronic pain after spinal cord injury: a systematic review and meta-analysis. Reg Anesth Pain Med. 2021;46(4):328-336.

9) Norrbrink Budh C, Hultling C, Lundeberg T. Quality of sleep in individuals with spinal cord injury: a comparison between patients with and without pain. Spinal Cord. 2004;43(2):85-95.

10) Sinnott A, Cassidy B, Nunnerley J, et al. Commentary on Community Participation Following Spinal Cord Injury in New Zealand. Top Spinal Cord Inj Rehabil. 2010;15(4):63-71.

11) Migliorini C, Tonge B, Taleporos G. Spinal Cord Injury and Mental Health. Aust N Z J Psychiatry. 2008;42(4):309-314.

12) Hilton G, Unsworth C, Murphy G. The experience of attempting to return to work following spinal cord injury: a systematic review of the qualitative literature. Disabil Rehabil. 2017;40(15):1745-1753.

13) International Standards for Neurological Classification of SCI (ISNCSCI) Worksheet - American Spinal Injury Association [Internet]. American Spinal Injury Association. 2019 [cited 18 April 2022]. Available from: https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/.

14) Boonstra A, Preuper H, Balk G, Stewart R. Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain. 2014;155(12):2545-2550.

15) Siddall P, McClelland J, Rutkowski S, Cousins M. A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury. Pain. 2003;103(3):249-257.

16) Cruz-Almeida Y, Alameda G, Widerström-Noga E. Differentiation between pain-related interference and interference caused by the functional impairments of spinal cord injury. Spinal Cord. 2008;47(5):390-395.

17) Smith M, Haythornthwaite J. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev. 2004;8(2):119-132.

18) Roehrs T. Does Effective Management of Sleep Disorders Improve Pain Symptoms? Drugs. 2009;69(Supplement 2):5-11.

19) Cardenas D, Emir B, Parsons B. Examining the Time to Therapeutic Effect of Pregabalin in Spinal Cord Injury Patients With Neuropathic Pain. Clin Ther. 2015;37(5):1081-1090.

20) Widerström-Noga E, Felipe-Cuervo E, Yezierski R. Chronic pain after spinal injury: Interference with sleep and daily activities. Arch Phys Med Rehabil. 2001;82(11):1571-1577.

21) Hauora: Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry [Internet]. Wellington. 2019 [cited Apr 18 2022]. Available from: https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_152801817/Hauora%20W.pdf.

22) Krause J, Broderick L, Saladin L, Broyles J. Racial Disparities in Health Outcomes After Spinal Cord Injury: Mediating Effects of Education and Income. J Spinal Cord Med. 2006;29(1):17-25.

23) Krause J, Saladin L, Adkins R. Disparities in subjective well-being, participation, and health after spinal cord injury: A 6-year longitudinal study. NeuroRehabilitation. 2009;24(1):47-56.

24) Myaskovsky L, Burkitt K, Lichy A, et al. The Association of Race, Cultural Factors, and Health-Related Quality of Life in Persons With Spinal Cord Injury. Arch Phys Med Rehabil. 2011;92(3):441-448.

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