Chronic pain experience and pain management in persons with spinal cord injury in Nepal

2.1 Participants and procedure

The participants (n=120) of this descriptive study included SCI persons with chronic pain purposively selected from community of eight districts of the Bagmati Zone, Nepal. Inclusion criteria of the study included (1) aged 18 years or older, (2) can communicate Nepali language, (3) experienced persistent pain for at least 3 months and (4) no history of cognitive impairment.

The participants were identified through the contact detail provided by a Spinal Injury Rehabilitation Center (SIRC) in Nepal. All participants were informed in advance regarding the purpose, procedure, risk and benefits of the study through telephone. Based upon the willingness of the participants, the researcher made appointment regarding the preferred place and time to visit them.

The participants were asked to sign the informed consent and if they were not able to read or write at their own, their family witnesses were asked to sign. Data collection was conducted from January to March, 2017. Individual assessment was done by a self-report and interview at participants’ preferred place (at their home or the outpatient clinic of SIRC), by the first researcher who is a Nepalese nurse.

2.2 Measures

2.3 Data analysis

Descriptive statistics was used to analyze demographic and SCI characteristics and chronic pain experience using frequencies, percentage, mean and standard deviation. Simple content analysis process was done to analyze the qualitative data from open-ended questions of pain management.

3.1 Demographic and SCI characteristics

A total of 120 participants were recruited into the study with an average age of 33 years (min=18, max=65). Almost three-fourths of the participants (71.67%) were male with Hindu as the dominant religion (75.83%). Almost half of the participants attended secondary school (44.17%). Duration of injury ranged from 1 to 24 years (median=5, IQR=7). More than half of the participants (56.67%) had injury at the thoracic level and one-fifth of the participants had injury at lumber level. Complete injury had occurred in almost two third of the participants (62.50%) and 90% of the total participants were paraplegic. After SCI, 85.00% of them had physical complications such as urinary tract infection, constipation, spasticity and pressure sore. Sixty percent of the participants were unemployed after SCI, and almost than three-fourths (74.17%) of all participants reported that their income were not sufficient for their daily living.

3.2 Chronic pain experience

Participants had pain in at least one body location. Back (n=88), lower legs/feet (n=66), and buttocks/hips (n=51) were found to be the most common pain locations. The onset of pain was found within the first 6 months of the injury, except for the head and frontal torso/genitals. Overall pain intensity was found to be at the moderate level (M=5.12, SD=1.80). Considering pain score of each location, the upper leg/thigh had the highest pain intensity score (M=6.50, SD=2.39) followed by buttock/hips (M=6.47, SD=2.24) (Table 1). On average, the pain interference was found to be at the moderate level (M=4.58, SD=2.30) (Table 2).

3.3 Pain management

Participants used pain medication and/or non-pharmacological management method to reduce their chronic pain. Fifty percent of SCI person used pain medications and 96% of them used non-pharmacological pain management methods. Detail regarding each has been mentioned below.

4.1 Chronic pain experience

In this study, the common onset of pain was found within the first 6 month of the injury. This finding was consistent with previous studies [9, 21]. Similarities are noted between current study findings and to that of previous studies [5, 22] where back and lower legs was identified as the common pain location. Majority of the participants in this study had SCI at thoracic and lumber level, this could have given pain in the lower legs/feet, since distal lower extremities were identified as the commonly reported pain locations among persons with injury at thoracolumbar level [21]. Moreover, it has been assumed that back and lower body pain were perceived more frequently possibly because they are more likely to be neuropathic in origin. However, this interpretation remains speculative in the absence of data classifying pain as neuropathic versus nociceptive in this study [23]. Furthermore, SCI persons in Nepal were found using seriously despaired wheelchair and low quality foam or cushions [24]. This could have exerted more pressure on their back. Since, several mechanical factors such as muscle weakness and straining produced by prolonged sitting [25], activity and positioning [26] were found contributing to the back pain among the SCI persons.

This study finding in regard to moderate level of pain intensity was consistent with previous studies [5, 22, 27]. The moderate level of pain intensity in this study could be due to the pain mechanism, secondary complications and an inadequate or inappropriate use of pain management methods.

Chronic pain has a negative impact on basic activities of daily living because higher pain intensity was associated with higher pain-related fatigue which influenced pain related interference with daily activities [7]. Furthermore, severity and chronicity of pain was higher at night than during the daytime that could have caused a disturbance in sleep among the SCI persons [28]. Sleep disturbance occurs as a result of a change in serotonergic neurons which resulted in hyperalgesia, thus interfering with the mood of the persons with chronic pain [29].

4.2 Pain management

Consistent with a previous study [30], half of the participants in this study used pain medications to reduce their intolerable pain. Ibuprofen was the most commonly used pain medication in this study since it is readily available in a pharmacy and it is a commonly used drug in Nepal [31]. This finding was consistent with the study done in Nepal among general population where self-medication and use of non-prescribed drugs were commonly practiced [32].

However, use of pain medications was lower than non-pharmacological pain management methods [13]. This result was possibly caused due to the lack of knowledge on the use of pain medication, disability associated and medical expense. Some participants stated the unsafe profile of pain medications, e.g. resistance to drugs, fear of drug dependency, side effects of drugs, and inability to afford the cost of pain medications. Consistently, previous studies showed that pain medications were perceived to be ineffective, unwanted side effects [30, 33], and cost effective among SCI persons [33]. A previous study done among persons with disability, expressed their limitation to go to hospital for checkup to get necessary primary care because of their disability associated [34].

In previous study massage was done either by hands or special devices using some specific technique for relief of low back pain [35], while in this study massage was done either by the person with SCI themselves or with the help of family members with the use of locally available mustard oil, fenugreek seed, camphor etc. without any formal training. Moreover, the frequent use of exercise was possible because it is cost effectiveness and could be carried out independently by SCI persons at home. Participants were expected to possess some knowledge on doing general exercises, since almost all of them were rehabilitated at the SIRC where exercise sessions were held regularly by the health professionals.

Consistent to the previous study [15, 36], distraction was found to be the common method of relaxation. Distraction was found as an alleviating factor for numb, distending, shooting, electric, burning and pricking pain sensations in different body locations [15], thus believed to decrease the pain intensity [36].

Coping was also performed among some participants of this study, for example, tolerance to pain and meditation and praying. This could be because of the dominance of Hindu people in Nepal. Hindu people view pain and suffering as a result of their unfolding “karma” or an inappropriate action done in the past or present. Therefore, Hindu people usually endure pain and cope well with the situation [37]. Furthermore, spiritual faith has been taken as a positive coping mechanism in relieving chronic pain in SCI [17]. Consistently, prayer helped to accept the reality and cope with the stressful situation among SCI person in Tehran [16].

Unlike to the developed countries the participants of this study were found using natural or homemade resources in Nepal such as hot compression (hot brick with clothes), use of patuka, and traditional herbs for their chronic pain relief. In Nepal, the traditional method of wrapping a homemade belt (patuka) around the waist is a common practice and is believed to provide spinal support for back pain relief [38]. A cross-sectional survey done in the central region in Nepal supported the hypothesis regarding the traditional use of wearing a patuka for the prevention of back pain among the groups of heavy workers and porters with back pain [38]. However, the mechanism of patuka on pain relief has rarely been known.

Moreover, Nepal is the arena for several herbal plants and ethnic medicines which are used to treat different health problems [39]. Asian traditional herbs were found alleviating cancer pain. However, an extensive evaluation of the effect of traditional Asian herbs on pain relief is lacking [40].