Neuropathic pain (also called central pain) is most common and most difficult to treat. Can cause referred pain in other area of body such as shoulder, neck and trapezius muscles in tetraplegia (18,93).

Allodynia (pain with typically non-painful stimulus) is a common type of neuropathic pain (18).

At or above level of lesion, can be back, buttocks/hips, legs/feet, and/or upper extremities (18,66).

Wheelchair use (transfers, propulsion, pressure relief) most commonly associated with shoulder, neck, elbow, wrist, and hand pain (6,11,18,25,50,66,98).

• Wheelchair use (6,18,50,66).
• Longer time with SCI (18,66).
• Advancing age (15,18,66).
• Decreased range of motion (15).
• Overweight or obesity (66).
• Injury at C6 or higher (15).
• Incomplete SCI may cause more pain and spasticity than complete SCI (66).
• Not starting shoulder exercises within 2 weeks on initial SCI (93).
• Lower levels of recreation/physical activity (25,71).

Pharmacotherapy (medications), physical therapy, acupuncture, and aromatherapy have not been rated as very helpful (18).

No single treatment has been shown to be effective for any pain problem in persons with SCI. A multidisciplinary / multimodal approach may be best (18,66,98).

Pharmacological

• Non-steroidal ant-inflammatory drugs (66).

Non-Pharmacological

• Education (11,66).
• Therapeutic modalities (66).
• Stretching (66).
• Exercise/recreation may reduce pain in addition to improving social integration and reducing depressive symptoms (71).
• Participation in wheelchair sports (mixed results, but study with sedentary wheelers as control showed positive results) (10,25)
• Reduce body fat (66).
• Change environment to place frequently viewed objects (TV, computer screen, phone) to appropriate height from wheelchair to minimize neck pain (50).
• Consider a wheelchair with a higher (or adjustable) seat height and ability to tilt back or recline trunk to minimize neck pain (50).
• Whenever possible, have friends, family and clinicians sit rather than stand while conversing with a wheelchair user (50).
• Whenever possible, have wheelchair seat and transfer destination heights equal to minimize upper extremity effort required (66).

Little has been studied or noted in regard to exercise and neuropathic pain. One small study showed no neuropathic pain relief with a bicycle ergometry exercise regimen in 4 people with SCI (80).

General Guidelines

• Optimized pain management may lead to greater exercise compliance (15).
• Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (15,39).

Frequency recommendations vary from once or twice daily strengthening/stretching shoulder exercises to 2- or 3-times weekly combined cardiovascular endurance and resistance training. Keep in mind that 2x weekly vs. 3x may increase compliance (11,15,39,66).

Aerobic Exercise / Flexibility Training

• Although aerobic endurance and flexibility exercises are important to overall health, there was no data available in this literature search relating to pain relief benefits.

Strength Training

• Begin a shoulder strengthening/stretching exercise regimen within two weeks of initial SCI (93).
• Stretch anterior shoulder musculature including pectoralis and bicep muscles; strengthen posterior shoulder musculature and maintain range of motion in shoulder, especially groups which control external rotations and adduction. Watch for and address any strength deficiencies or imbalances (11,66).
• Stretch scapularic protractors; strengthen scapularic retractors (11,66).
• Rowing exercises or backward wheeling, through sports or other activities, can strengthen scapularic retractors (25,66).
• Wall pulley exercises, free weights, exercise bands, wheelchair friendly weight machine with or without wrist straps can all work well in devising a resistance training program for persons with SCI (11, 39).

• High pain intensity (18).
• Pain in several locations (98).
• Gunshot wound etiology (some but not all studies) (18,71).
• Social isolation (71).