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Spinal Cord Injury Pain Quick Steps

Complete the quick steps for each type of pain

Determine the level and completeness of the spinal cord injury

Does the patient have

Paraplegia (normal movement and feeling in the upper limbs, but absent or abnormal in lower limbs and trunk) or

Tetraplegia (absent or abnormal movement or feeling in the upper and lower limbs and trunk)?

What level is the spinal cord injury?

(e.g. L4)

Is the injury

Complete (unable to move and feel any part of the body below the level of injury) or

Incomplete (able to move and/or feel some parts of the body below the level of injury)?

Determine the type of pain present (may be more than one)

Please specify details of the pain in the grid below. If the pain is another type of pain not listed on the grid or is unknown, please indicate in the text box below the grid.

Neuropathic pain

Musculoskeletal pain

Visceral pain

Pain features

Burning, electric shock-like, pricking, pins and needles, sharp, shooting, hot-burning, tingling, squeezing, cold, electric, or shooting pain
More about neuropathic pain

Aching, sharp, dull, posture or movement related
More about muskuloskeletal pain

Dull, cramping, tender
More about visceral pain

Above the level of injury
e.g. above T4

At the level of injury

Below the level of injury
e.g. above T4

Other type of pain or unknown (e.g. irritable bowel syndrome, complex regional pain syndrome)

What is the average intensity of the worst pain over the last week?

What is the average intensity of pain on a scale of 0 - 10 / 10?

where 0 = no pain and 10 = pain as bad as you can imagine

Do history and examination suggest an underlying (red flag) condition?

The following are red flag conditions

New pain with recent change in sensory or motor function

Generalised systemic symptoms

Autonomic dysreflexia

Change in bladder function

Change in bowel function

Pressure injury

Recent fall or trauma

Are the prescribed medications appropriate and effective in improving function and reducing pain? i.e. (sufficient pain relief and daily function in spite of pain)

View flowchart

Are there indicators of medication risk or substance misuse?

Indicators of risk or misuse may include:

Dose > 40mg morphine equivalent per day (Opioid Calculator Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists)

Treatment duration > 90 days

Opioid risk tool > 3 (Pain Management Network Opioid Risk Assessment Tool)

Side effects from OTC and other medications evident

Social impact of drug and alcohol misuse (AUDIT (Alcohol Use Disorders Identification Test) Saunders JB)

Is pain interfering with day to day activities (e.g. transfers, push distance, time in the chair, mobility)

On average, how much has pain interfered with your day to day activities in the last week?

Rate yourself between 0 and 10, where 0 = no interference and 10 = extreme interference

Are other treatments indicated?

View possible treatments (procedures and interventions)

Is pain interfering with mood?

How much has pain interfered with your mood in the last week?

Rate yourself between 0 and 10, where 0 = no interference and 10 = extreme interference

Is pain interfering with sleep?

How much has pain interfered with your sleep in the last week?

Rate yourself between 0 and 10, where 0 = no interference and 10 = extreme interference

Is weight interfering with transfers, wheelchair propulsion, compromising skin integrity?

Is the patient actively engaged in self management?

Consider if the person is

Maintaining normal activities despite pain (at home or work)

Using non-drug ways of self-calming (e.g. relaxation, meditation, gentle exercise)

Taking a problem-solving approach to managing their pain (not expecting doctor to sort it out alone)

Minimising alarmist thinking

Minimising avoidant behaviours

Is the patient actively engaged in self management?

Do you have any additional notes to add to the Pain Management Plan?

When to consider referral to or phone consultation with a pain specialist or clinic

  • Declining physical function
  • Presence of complicating or persisting red flags
  • Co morbid yellow flags or increasing psychological distress: K10 > 19, Orebro > 50, BPI interference score > 50
  • Excessive health care use and or multiple medications for pain
  • Difficulty weaning chronic opioid therapy
  • Significant opioid risk:
    • opioid morphine equivalent dose > 40mg moderate risk of harm
    • opioid morphine equivalent dose > 100mg high risk of harm
    • opioid use > 90 days

Tertiary referral and advice

For complex pain presentations or pain which is not responding to primary care level treatment, consider referral to tertiary pain and/or spinal services.