Pain as a complication of spinal cord injury (SCI) has been identified as a primary determinant of quality of life. Although pain is a frequent complication of SCI, few studies have directly examined the effectiveness of various pain management interventions in this population. The primary goal of the proposed project is to improve the management of chronic pain in persons with SCI. Although all types of pain can occur in SCI, dysesthetic/deafferentation pain is the most common and disabling. The tricyclic antidepressant medications have been found to be most effective pharmacologic treatment for relieving deafferentation pain. Current research in chronic pain has demonstrated the importance of psychosocial factors, including cognition and emotions. Consequently, behavioral interventions have been successful in improving function and reducing disability and handicap. Multidisciplinary approaches utilizing combinations of treatment modalities, such as pharmacological and psychological interventions, are now recognized as the standard of care in chronic pain management. The proposed project will examine the efficacy of two primary interventions for managing chronic pain, nortriptyline or cognitive-behavioral treatment, and their combination in reducing SCI-related pain, disability, and handicap. In addition to comparing the relative effectiveness of medical and behavioral interventions, this project will examine whether individual patient characteristics, such as depression, predict responses to these treatments and whether treatment gains are maintained at 6-month follow- up. Persons with persistent pain for 6 months or longer following SCI will be enrolled in this randomized controlled study which incorporates a 2 group (nortriptyline versus placebo) by 2 group (cognitive-behavioral versus self-care eduction) design. After completing a baseline assessment, each patient will undergo 10 weeks of active treatment that will include weekly psychological intervention and daily use of medication. Following completion of the active phase of treatment, patients will enter a 6-month maintenance and follow-up period. Outcome measures will assess pain, physical and psychosocial function, use of medication for pain, and use of the health care system. Evaluation of a treatment approach combining commonly used psychological and pharmacological approaches promises to promote the development of truly effective programs. Findings derived from this project will lead to further studies that determine which treatments, or combinations of treatments, are effective for specific subgroups of SCI patients and other chronic pain populations. These results will advance the design of individual treatment programs and further improve treatment outcomes.
