Acute inflammatory musculoskeletal pain often follows direct trauma to musculoskeletal structures and there is
little that can be done to remove the cause. Pain usually resolves, however, as healing occurs. Damage due to unstable skeletal structures requires stabilization using external devices or internal fixation. Symptomatic pain management, as described below, may be required during the tissue-healing phase.
Chronic inflammatory musculoskeletal pain may be due to factors such as abnormal posture, abnormal gait, and overuse, related to transfers and wheelchair use. These factors may be corrected via education, retraining, and environmental modifications (e.g. adaptive equipment, seating modification, and attendant care prescription) and may be sufficient to eliminate the problem. In the short term, or if it is not possible to completely address the causative factors, symptomatic treatment may also be required.
In addition to correcting abnormal mechanical stresses, managing active disease processes, and modifying unhelpful psychosocial contributing factors, symptomatic pharmacological treatment of inflammatory muscu-loskeletal pain may be indicated. Similar principles can be used as those employed in the treatment of other degenerative and inflammatory joint conditions.44 [V] Pharmacological management includes the use of simple analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and local corticosteroid injections. Analgesic use will follow the usual stepwise approach of simple analgesics, such as paracetamol (acetaminophen), compound or "weak" opioids, such as codeine and dextropropoxyphene, and "strong" opioids such as oxy-codone, morphine, and methadone. However, several considerations apply in the person with SCI. Opioid analgesics may exacerbate bowel dysfunction, as well as the usual considerations of tolerance and dependence. NSAIDs may cause gastric erosion that is more prevalent and harder to detect in those with high spinal cord lesions. Therefore, paracetamol is the safest first step in the treatment of musculoskeletal pain associated with SCI. If there is no response to paracetamol, the use of tramadol may be considered. While use of opioids for acute inflammatory pain is reasonable, continued use in persistent pain remains controversial.45 There is general agreement that opioids should be considered for use in noncancer pain if they are the only effective treatment.46 Unfortunately, conclusive data supporting the long-term efficacy of opioids remains lacking.47 The use of opioids may be considered on a case-by-case basis in a manner consistent with published guidelines.48
Muscle spasm is also a common problem following SCI, associated with tissue trauma and altered inhibitory control. In addition to impairing function, spasm may also cause pain. Muscle spasm may be due to underlying pathology that is maintaining a heightened reflex arc. If so, this needs to be treated appropriately. More commonly, there is no underlying pathology that can be addressed and treatment once again focuses on symptomatic relief. At present, there is insufficient evidence to guide clinicians in a rational approach to anti-spastic treatment for SCI.49[I] A number of approaches are traditionally used. Oral baclofen may be sufficient to control the symptoms and is the first-line approach. Alternatively, diazepam may be used, but consideration must be given to the side effects associated with benzodiazepine use. Injection of botulinum toxin has also been suggested to be effective in the management of localized spasticity.50 Insertion of an intrathecal infusion device is invasive and is considered a second-line approach. However, there is good evidence to support the effectiveness of intra-thecal baclofen administered in this way for the relief of muscle spasm where there is poor control with oral administration.51,52,53 [I]
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