European Journal of Pain 13 (2009) 511–517

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European Journal of Pain

journal homepage: www.EuropeanJournalPain.com

Spinal cord injury-related pain in rehabilitation: A cross-sectional study ofrelationships with cognitions, mood and physical function

Kathryn Nicholson Perry a,b,*, Michael K. Nicholas a, James Middleton b,c

a The University of Sydney Pain Management and Research Centre, Royal North Shore Hospital, Sydney, Australiab NSW Statewide Spinal Cord Injury Service, Royal Rehabilitation Centre, Sydney, Australiac Rehabilitation Studies Unit, University of Sydney, Australia

a r t i c l e i n f o a b s t r a c t

Article history:Received 14 March 2008Received in revised form 22 May 2008Accepted 7 June 2008Available online 23 July 2008

Keywords:CatastrophizingMoodDisabilitySpinal cord injuryPainSelf-efficacy

1090-3801/$36.00 � 2008 European Federation of Chdoi:10.1016/j.ejpain.2008.06.003

* Corresponding author. Present address: School oCallum Building A18, University of Sydney, NSW 2001113 fax: +61 29036 5223.

E-mail address: kathrynn@psych.usyd.edu.au (K. N

Although psychological aspects of SCI-related pain have been investigated in those with chronic pain, lit-tle data is available regarding these factors in those early in the course of the injury. Using a sampleadmitted for SCI rehabilitation, this paper describes the relationships between usual pain intensity, mood,disability and both pain and SCI-related psychological factors. The sample were largely similar to othersamples of individuals with SCI-related chronic pain in terms of mood, but were noted to be less cata-strophic in their thinking about pain than a comparative pain clinic sample. They also reported SCIself-efficacy and acceptance scores consistent with other SCI samples. Compared with other SCI popula-tions there were mixed findings in relation to physical disability. Consistent with previous findings inchronic pain SCI samples, usual pain intensity was found to have a strong relationship with symptomsof anxiety and depression, and pain-related life interference. SCI acceptance was significantly negativelyassociated with depression scores, pain catastrophizing was significantly positively associated with bothanxiety and depression scores, and SCI self-efficacy was significantly negatively associated with bothanxiety and depression scores. SCI self-efficacy was also significantly positively associated with physicalfunction scores. These findings suggest that pain-related psychological factors may have importance evenearly in the clinical course following SCI, but that it is important, however, to consider more general SCI-related psychological factors alongside them. In addition, these findings suggest the possibility that earlyinterventions based upon the cognitive behavioural treatment of pain may be integrated into SCI rehabil-itation programmes.� 2008 European Federation of Chapters of the International Association for the Study of Pain. Published

by Elsevier Ltd. All rights reserved.

1. Introduction

Spinal cord injury (SCI) is a devastating condition, commonlyassociated with traumatic circumstances of onset. It has lifelongimplications for both the individual and those close to them, andis associated with increased levels of psychological distress (Ken-nedy et al., 2000). Persistent pain is reported in approximately65% of people affected by the condition (Siddall et al., 2003), andis documented as significantly impairing function and mood (Nep-omuceno et al., 1979; Rose et al., 1988; Mariano et al., 1989; Craiget al., 1994; Kennedy et al., 1997).

There are few studies of pain early in the course of SCI, and evenfewer have examined the role of psychological variables at thatstage (Craig et al., 1994; Cairns et al., 1996; Kennedy et al., 1997;

apters of the International Associa

f Psychology, Brennan Mac-6, Australia. Tel.: +61 40862

icholson Perry).

New et al., 1997; Siddall et al., 1999, 2003; Murray et al., 2007).Pain has consistently been found to be associated with symptomsof psychological distress among those undergoing SCI rehabilita-tion, but other components of biopsychosocial models of pain haveyet to be examined. Among those with chronic pain related to SCI,other psychological variables have recently been identified as sig-nificant in the relationship between chronic pain and mood, in par-ticular cognitions (Turner et al., 2002; Giardino et al., 2003; Raichleet al., 2007; Wollaars et al., 2007). However, there is also recentevidence that more general aspects of adjustment to SCI are impor-tant in predicting quality of life among those with chronic SCI-re-lated pain (Wollaars et al., 2007). This suggests that pain variablesmay need to be considered within a broader framework to effec-tively understand quality of life in those with SCI-related pain.These findings are significant because of the potential treatmentimplications among those with chronic SCI-related pain. However,if such relationships were also found to be present among thoseearlier in the course of SCI, it may have implications for the preven-tion of chronic pain-related disability and distress.

tion for the Study of Pain. Published by Elsevier Ltd. All rights reserved.

512 K. Nicholson Perry et al. / European Journal of Pain 13 (2009) 511–517

The purpose of the present study was to conduct an explorationof pain-related and SCI-related psychological factors and their con-tribution to disability and psychological distress in the rehabilita-tion period following an SCI. The hypotheses for the study werethat:

(1) Usual intensity of pain would be significantly associatedwith mood and disability.

(2) Pain catastrophizing would be significantly associated withmood and disability.

(3) SCI self-efficacy and acceptance would be significantly asso-ciated with mood and disability.

2. Methods

2.1. Subjects

From 2004 to 2006, 105 patients admitted for rehabilitation fol-lowing SCI to a specialist SCI rehabilitation unit in Sydney (NSW,Australia) were asked by the unit’s clinical psychologists to com-plete the measures as part of their admission assessment, and allwere asked to give consent to participate in the study. Ethical ap-proval for the study was obtained from the relevant committee.The questionnaires took approximately 45 min to complete. Indi-viduals were given assistance to complete the questionnaires ifimpairment of upper limb function prevented them from doingso independently, and in the event of fatigue or other factors theycould be completed over more than one session. All participantshad experienced a recent SCI and been medically stabilized priorto being transferred for specialist rehabilitation. Inclusion criteriaincluded having sustained SCI requiring admission to a specialistSCI rehabilitation centre, and exclusion criteria included: com-mand of English inadequate to complete questionnaires; presenceof current psychotic disorder; and traumatic brain injury sufficientto interfere with completion of questionnaires (history of loss ofconsciousness and post-traumatic amnesia of 24 h duration orlonger). Forty-seven individuals completed the questionnairesand consented to participate in the study (a participation rate of45%). In most cases, failure to participate was related to the multi-ple competing demands on the time of those participating in reha-bilitation, such as urgent requirements for other medicalassessments or therapy appointments, resulting in questionnairesnot being completed. Only those reporting pain completed the painspecific questionnaires.

2.2. Measures

Participants completed a battery of questionnaires, describedbelow.

2.2.1. Researcher developed demographic checklist and pain measureThis records age and gender; marital, educational and occupa-

tional status (based on a standardized hospital format); neurolog-ical level, completeness of impairment, date of SCI; and sites,current, highest, lowest and usual intensity of pain on 11-pointnumerical rating scales (based upon Daut et al., 1983).

2.2.2. Moorong self-efficacy scale (MSES)This is a 16-item self-report questionnaire (Middleton et al.,

2003) that assesses respondent’s confidence in their ability to com-plete a range of daily tasks on a seven-point Likert scale from 1,‘very uncertain’, to 7, ‘very certain’. The total scale score is obtainedby calculating the sum of the individual scores with a range from16 to 112, with higher scores indicating higher levels of confidence.

Reliability and validity has been established within an Australiansample of people with SCI. The Cronbach alpha coefficient in thecurrent study was 0.93.

2.2.3. Spinal cord lesion-related coping strategy questionnaire (SCLCSQ)

This is a 12-item self-report questionnaire (Elfstrom et al., 2002,2003, 2005) that assesses the degree to which the respondent en-dorses a series of statements representing three coping strategiesused by people with SCI: acceptance (revaluation of life values);fighting spirit (minimizing the effect of the injury); and social reli-ance (tendency toward dependent behaviour). Participants re-spond on a four-point scale from 1, ‘strongly disagree’, to 4,‘strongly agree’. Scores for each domain are obtained by calculatingthe mean value of each item within that domain, giving an overallscore between one and four, with higher scores indicating higherendorsement of the domain. Only the acceptance sub-scale hasbeen found to be valid in the English translation (Elfstrom et al.,2007), and therefore only this sub-scale is reported. The Cronbachalpha coefficient for the acceptance sub-scale in this study was0.83.

2.2.4. Pain response self-statements scale – Catastrophizing sub-scale(PRSS Catastrophizing)

This is a nine-item self-report inventory (Flor et al., 1993) thatmeasures the frequency of a patient’s catastrophic cognitions thatimpede the individual’s ability to cope with severe pain. Patientsare asked to rate on a six-point scale how often they think in a spe-cific way when experiencing severe pain, from 0, ‘almost never’, to5, ‘almost always’. The average score for all nine items is calcu-lated, with a higher score indicating more frequent occurrence ofcatastrophic thinking. The scale was validated on a sample ofchronic pain patients (Flor et al., 1993) and norms are availablefor individuals with pain attending an Australian tertiary referralpain management centre (Nicholas et al., 2008). The Cronbach al-pha in this sample was 0.88.

2.2.5. Multidimensional pain inventory – SCI version (MPI-SCI)This is a modified version of the West Haven-Yale Multidimen-

sional Pain Inventory (Kerns et al., 1985), which is a 60-item self-report questionnaire based upon the cognitive behavioural modelof chronic pain. This has been shown to have excellent psychomet-ric properties and is widely used. A modified version for SCI hasbeen developed, and the consistency and validity examined (Wide-rström-Noga et al., 2002, 2006). The measure is in three parts, butin this case only the Life Interference sub-scale of Part 1 was useddue to the restrictions on an individual’s activities following a re-cent injury, and their location away from their usual environment,meaning that many of their usual activities were not available tothem. This provides an overall estimation of the perceived interfer-ence of pain on physical functioning and is recommended by theIMMPACT as a core outcome measure (Dworkin et al., 2005).

2.2.6. Hospital and anxiety depression scale (HADS)This is a 14-item self-report inventory (Zigmond and Snaith,

1983) which assesses the frequency of symptoms on an anxietysub-scale (seven items) and depression sub-scale (seven items).Respondents rate each item on a four-point scale from 0, ‘not atall’, to 3, ‘very often indeed’. Scores for each sub-scale are summed,with higher scores indicating higher frequency of symptomatologyassociated with anxiety and depression. It has been widely used inpopulations with physical pathology, including post-SCI with ade-quate internal consistency (Woolrich et al., 2006). It is considereduseful in such populations because of the relative lack of somaticitems. In the current study the Cronbach alpha coefficient was 0.87.

K. Nicholson Perry et al. / European Journal of Pain 13 (2009) 511–517 513

2.2.7. Medical outcomes study short form health survey-12 (SF-12)This is a 12-item self-report questionnaire (Ware et al., 1996)

that assesses symptoms, functioning and quality of life. It gener-ates a Mental Component Score (MCS) and Physical ComponentScore (PCS). It uses a sub-set of items of the longer Medical Out-comes Study Short Form Health Survey-36 (SF-36) that was de-signed for use in general practice. It has been validated for useamong people with SCI (Forchheimer et al., 2004) which found thatneurological impairment was associated with the PCS but not theMCS. A scorer validated on the Australian community was usedto score the responses (Andrews, 2002). Scores on each componentare designed to have a mean of 50 and standard deviation of 10,with lower scores denoting greater disability. Scores between 40and 50 represent mild disability, between 30 and 40 representmoderate disability and 30 and below represent severe disability.

2.3. Statistical methods

All analyses were conducted using the SPSS 12 statistical com-puter package. Due to missing values in some data, participantswith missing data of less than 10% on an individual scale had theindividual items replaced with a pro-rated value based on theirother responses to that scale. In the event that more than 10% ofvalues of a scale for an individual participant were missing, theoverall response for that scale was scored as missing. The distribu-tion of all study variables was inspected to ensure that they metthe assumptions of the statistical tests performed for the study.All tests were two-tailed. Statistical significance was set atp < 0.05. Significance was adjusted using the Bonferroni correctionto protect against errors due to the large number of calculations.

Participants and non-participants in the research were com-pared on demographic and SCI variables. Those with and withoutpain were also compared on demographic and SCI variables. Inthe case of categorical values the chi-square or Fisher’s exact testwas used, the latter to account for the small sample size and thelikelihood of insufficient cases in each cell for the use of the chi-square test; for continuous variables the two-sample t-test wasused.

Pearson correlation coefficients were calculated between usualpain intensity and the other variables. The scores of the wholesample on each of the measures were compared with availablenorms using two-sample t-tests.

The sample was then divided into those with and without pain.Usual pain intensity scores measure were re-coded into ‘no or min-imal’ (0–3), ‘moderate’ (4–6), and ‘severe’ (7–10) categories (Han-ley et al., 2004). The group was then divided into those withclinically insignificant (‘no or minimal’) and clinically significant(‘moderate or severe’) pain. As the results violated the assumptionof normality when divided in this way, comparisons in the scoresbetween the groups on each variable were conducted using theappropriate non-parametric test, the Mann–Whitney U (orsigned-ranks) test.

Table 1Comparison of demographic and SCI variables for participants and non-participants, and t

SCI/demographic variable Participants n = 47 Non-participants n = 58 Statist

Level of injury 1.367Paraplegia 24 (51%) 23 (40%)Tetraplegia 23 (49%) 35 (60%)Completeness 0.988Complete 21 (45%) 26 (45%)Incomplete 26 (55%) 32 (55%)ASIA score 6.890A 18 (46%) 27 (47%)B 10 (26%) 15 (26%)C 10 (26%) 6 (10%)D 1 (2%) 9 (16%)

3. Results

3.1. Description of sample

Demographic and SCI characteristics are described in Table 1.The mean age of the group was 39.8 years (SD = 15.15), and therewere 39 males (83%). There were no significant differences in age,gender or SCI factors between those who did and did notparticipate.

3.2. Characteristics of pain

Thirty-six individuals (76.6%) reported the presence of pain insome location, with a mean usual intensity of 3.45 (SD = 2.66).Thirty-five and twenty-two percent of those with pain respectivelyreported usual pain levels of ‘moderate’ or ‘severe’ intensity (Han-ley et al., 2004). Compared with the reported mean usual intensityof pain of 6.4 (SD = 2.1) among a general pain clinic population(Nicholas et al., 2008), the mean usual pain intensity of this samplewas significantly lower (t (34) = 6.55, p < 0.005).

The sample was divided into those with pain and those withoutpain, and the two groups were compared (see Table 1) in terms ofkey demographic (age and gender) and SCI variables (level andcompleteness of injury). There were no significant differences be-tween the two groups.

3.3. Usual pain intensity, appraisals of SCI and pain, mood and physicalfunction

The mean scores for the whole sample on each of the variableswere calculated (see Table 2).

3.3.1. Appraisals of pain and SCIMean scores on the MSES were not significantly different to

those reported among a rehabilitation sample in the initial reportof the psychometric properties of the scale (Middleton et al.,2003; t(66) = 0.478, p = 0.634). Mean scores on the SCL CSQ Accep-tance sub-scale were not significantly different when comparedwith the values reported in the UK sample used to validate theEnglish language version of this scale (Elfstrom et al., 2007;t(80) = �1.169, p = 0.247). The mean reported level of pain catas-trophizing among those with pain was 1.78 (SD = 1.67), and meanscores in this sample were significantly less than that seen in astandard chronic pain clinic population (Nicholas et al., 2008;t(34) = 3.77, p < 0.005).

3.3.2. MoodCompared with the norms from a UK study of community living

people with SCI, there were no significant differences between themean scores on the anxiety or depression sub-scales of the HADSreported in the two samples (Woolrich et al., 2006). In this sample,29% and 36% respectively had scores indicating possible depressive

hose with and without pain (number of cases (%))

ic (v2) P-value No pain n = 11 Pain n = 36 Statistic (v2) P-Value

0.324 3.253 0.0933 (27%) 21 (58%)8 (73%) 15 (42%)

0.573 4.080 0.0812 (18%) 19 (53%)9 (82%) 17 (47%)

0.075 5.815 0.0952 (22%) 16 (53%)2 (22%) 8 (27%)4 (45%) 6 (20%)1 (11%) 0 (0%)

Tabl

e2

Corr

elat

ions

betw

een

usua

lpa

inin

tens

ity

and

othe

rva

riab

les

(N=

47)

Var

iabl

esM

edia

n(m

in–m

ax)

Mea

n(S

D)

SCL

CSQ

acce

ptan

ceM

SES

PRSS

cata

stro

phiz

ing

MPI

-SC

Ili

fein

terf

eren

ceSF

-12

MC

SSF

-12

PCS

HA

DS

anxi

ety

HA

DS

depr

essi

on

Usu

alpa

inin

ten

sity

3.00

(0–9

.00)

3.45

(2.6

6)�

.326

n=

40�

.465

an

=41

.717

an

=29

.650

an

=29

�.2

54n

=32

�.4

40n

=32

.659

an

=42

.668

an

=42

SCL

CSQ

acce

ptan

ce3

(1–4

)3.

02(0

.65)

�.3

62n

=45

.232

n=

28.1

72n

=29

.129

n=

36.1

86n

=36

�.3

72n

=45

�.4

50a

n=

45M

SES

89(1

6–11

2)86

.33

(20.

45)

�.2

81n

=29

�.1

93n

=30

.209

n=

37.4

45a

n=

37�

.515

an

=46

�.6

11a

n=

46PR

SSca

tast

roph

izin

g2.

00(0

.11–

4.13

)1.

74(1

.16)

.609

an

=28

�.0

61n

=24

�.5

10n

=24

.638

an

=29

.564

an

=29

MPI

-SC

Ili

fein

terf

eren

ce2.

38(0

–5.2

5)2.

08(1

.46)

�.2

75n

=25

�.5

51a

n=

25.6

56a

n=

30.4

83n

=30

SF-1

2M

CS

41(2

5–56

)41

.46

(7.0

2).0

89n

=37

�.1

06n

=37

�.1

68n

=37

SF-1

2PC

S39

(19–

52)

39.5

9(6

.77)

�.7

07a

n=

37�

.369

n=

37H

AD

San

xiet

y6

(0–4

)5.

87(4

.19)

.635

an

=47

HA

DS

depr

essi

on6

(0–1

8)5.

94(3

.72)

–

Not

e:SC

LC

SQ,S

pin

alC

ord

Lesi

on-R

elat

edC

opin

gSt

rate

gies

Qu

esti

onn

aire

;M

SES,

Moo

ron

gSe

lf-E

ffica

cySc

ale;

PRSS

,Pai

n-R

elat

edSe

lf-S

tate

men

tsQ

ues

tion

nai

re;

MPI

-SC

I,M

ult

i-D

imen

sion

alPa

inIn

ven

tory

(SC

IVer

sion

);SF

-12

MC

S,M

edic

alO

utc

omes

Stu

dySh

ort

Form

Hea

lth

Surv

ey-1

2M

enta

lCom

pon

ent

Scal

e;SF

-12

PCS,

Med

ical

Ou

tcom

esSt

udy

Shor

tFo

rmH

ealt

hSu

rvey

-12

Phys

ical

Com

pon

ent

Scal

e;H

AD

S,H

ospi

talA

nxi

ety

and

Dep

ress

ion

Scal

e.a

Cor

rela

tion

isst

atis

tica

lly

sign

ifica

nt

atth

e0.

006

leve

l.

514 K. Nicholson Perry et al. / European Journal of Pain 13 (2009) 511–517

and anxiety symptomatology (Zigmond and Snaith, 1994), which isconsistent with other studies of the SCI population (Hancock et al.,1993; Woolrich et al., 2006). Mean scores on the SF-12 MCS in thissample are significantly different to those reported in a sample of215 community living people with SCI in the USA (Forchheimeret al., 2004), with scores in this sample being significantly lower(t(74) = �8.61, p < 0.001). The mean score for this sample wouldfall into the moderate category whereas the comparison groupwould fall into the mild category. This may be due to the differenttime point at which the measures were taken.

3.3.3. Physical functionMean scores on the SF-12 PCS in this sample are significantly

different to those reported in a sample of 215 community livingpeople with SCI in the USA (Forchheimer et al., 2004), with thestudy sample’s scores being significantly higher (t(66) = 4.64,p < 0.001). However, the clinical significance of this difference isquestionable as both scores would fall within the mild disabilitycategory. Mean scores on the MPI-SCI Life Interference sub-scalewere significantly lower (t(43) = �2.74, p < 0.01) than those in aUS study of the use of this measure in a community living SCI pop-ulation with chronic pain (Widerstrom-Noga et al., 2004) indicat-ing less interference due to pain in this sample.

3.4. Correlations between variables

Correlations between usual pain intensity and other variablesare reported in Table 2.

3.5. Comparison of those with no pain, clinically insignificant andclinically significant pain

The group was then divided into those with and without pain,and the two groups compared on the variables of interest (see Ta-ble 3). While there were a number of statistically significant differ-ences between the two groups, only those of the SF-12 PCSappeared to be of a magnitude that may be clinically significant.

The group was then further divided into those with and withoutwhat is regarded as a clinically significant level of pain (‘moderateto severe’ in intensity; Hanley et al., 2004) and compared on eachof the variables (see Table 4). It is notable that on this basis thereappeared to be clinically significant differences in the case of anx-iety and depression scores (where the anxiety scores for those withclinically significant pain were in the range of possible disorder,and the depression scores in this sub-group were closely approach-ing this level; Zigmond and Snaith, 1994).

Differences of potential clinical significance were also noted inMSES scores when the sample was divided in these ways.

4. Discussion

4.1. Pain, mood and disability

The majority (76.6%) of those in this cohort of individuals enter-ing rehabilitation following an SCI reported the presence of pain.While the mean level of pain fell in the ‘mild’ range, around halfof the participants reported ‘moderate’ or ‘severe’ pain. These re-sults were consistent with the previous reports by Siddall and col-leagues (1999). While overall the usual intensity of pain reportedwas less than that among patients of a local tertiary pain clinic,17% of the current sample reported usual levels of pain consistentwith that sample. Consistent with other studies, demographic andSCI variables were unrelated to the presence of pain.

The reported mean level of psychological distress fell within thenormal range based upon studies of the general population,

Table 3Comparison between those with and without pain

No pain n = 11 Pain n = 36 Statistic (U)P-Value

Median (min–max) Mean (SD) Median (min–max) Mean (SD)

SCL CSQ acceptance 4 (1.5– 4) 3.56 (0.82) 3 (1–4) 2.96 (0.67) 68.50 0.003MSES 105 (69–111) 99.11 (14.95) 88 (16–106) 83.46 (21.53) 84.00 0.009HADS anxiety 2 (0–3) 3.09 (4.09) 6.5 (0–14) 6.27 (3.66) 93.50 0.007HADS depression 4 (0–2) 4.67 (3.67) 6 (1–12) 5.73 (3.03) 126.00 0.072SF-12 MCS 45 (38–56) 45.78 (6.02) 40.5 (25–55) 40.81 (6.49) 66.00 0.033SF-12 PCS 47 (30–52) 44.44 (7.00) 38 (19–47) 38.35 (5.98) 53.00 0.008

Significance adjusted for multiple comparisons p < 0.008.Note: SCL CSQ, Spinal Cord Lesion-Related Coping Strategies Questionnaire; MSES, Moorong Self-Efficacy Scale; SF-12 MCS, Medical Outcomes Study Short Form HealthSurvey-12 Mental Component Scale; SF-12 PCS, Medical Outcomes Study Short Form Health Survey-12 Physical Component Scale; HADS, Hospital Anxiety and DepressionScale.

Table 4Comparison between those with and without clinically significant levels of usual pain intensity

Clinically insignificant pain n = 24 Clinically significant pain n = 19 Statistic (U) P-Value

Median (min–max) Mean (SD) Median (min–max) Mean (SD)

PRSS catastrophizing 0.61 (0.11–3.00) 1.08 (0.96) 2.33 (0.56–4.13) 2.27 (1.02) 31.50 0.004SCL CSQ acceptance 3.63 (1–4) 3.18 (0.91) 3.00 (2.25–3.75) 3.00 (.45) 156.50 0.126MSES 101.50 (16–112) 91.96 (22.95) 85.50 (40–105) 82.50 (15.49) 121.00 0.009HADS anxiety 3.00 (0–13) 3.58 (3.67) 8.00 (4–14) 8.83 (2.83) 58.00 0.000HADS depression 3.50 (0–12) 4.25 (3.03) 7.50 (3–12) 7.94 (2.44) 74.00 0.000SF-12 MCS 43.00 (33–56) 43.47 (5.60) 38.00 (25–55) 38.73 (8.15) 85.00 0.047SF-12 PCS 44.00 (30–52) 42.37 (6.23) 38.00 (19–46) 36.07 (6.55) 70.50 0.011MPI-SCI life interference .69 (0–3.25) 1.14 (1.20) 3.13 (1.75–5.25) 3.00 (.88) 21.50 0.000

Significance adjusted for multiple comparisons p < 0.008.Note: SCL CSQ, Spinal Cord Lesion-Related Coping Strategies Questionnaire; MSES, Moorong Self-Efficacy Scale; PRSS, Pain-Related Self-Statements Questionnaire; MPI-SCI,Multi-Dimensional Pain Inventory (SCI Version); SF-12 MCS, Medical Outcomes Study Short Form Health Survey-12 Mental Component Scale; SF-12 PCS, Medical OutcomesStudy Short Form Health Survey-12 Physical Component Scale; HADS, Hospital Anxiety and Depression Scale.

K. Nicholson Perry et al. / European Journal of Pain 13 (2009) 511–517 515

however, around a third of individuals reported levels of depres-sive and anxious symptomatology that were suggestive of clini-cally significant distress (Zigmond and Snaith, 1994). Thesefindings are consistent with rates of depressive and anxious symp-tomatology found in other studies in rehabilitation and communitysamples (Judd et al., 1989; Dryden et al., 2005; Woolrich et al.,2006).

Perhaps unexpectedly, the sample’s scores on the SF-12 MCSand PCS scores were significantly different from those in anothersample of people with established SCI, however, the clinical signif-icance of this is questionable. It is also noted that some of the rela-tionships seen with the HADS measure of psychological distresswere not found with the SF-12 Mental Component Score, and thereason for this is unclear. However, unlike previous studies thepresent one used the 12-item version of the measure, and the reli-ance on items related to daily activities that are inaccessible duringthe inpatient rehabilitation period may mean that it is not suffi-ciently discriminative at this phase. In contrast, the HADS, withthe relative lack of behavioural items included, may be more sen-sitive to psychological distress during this period.

There was a strong positive association between usual painintensity and psychological distress, and there were significant dif-ferences in usual pain severity when those with and without pos-sible clinical levels of anxiety and depression were compared. Thisis consistent with findings both in rehabilitation and communitysamples (Craig et al., 1994; Kennedy et al., 1997; Turner et al.,2001; Jensen et al., 2005).

4.2. Pain and SCI-related appraisals and their relationships with moodand disability

The observed levels of both SCI self-efficacy and acceptancewere consistent with previous studies of community samples of

people with SCI. Pain catastrophizing in the current sample wassignificantly lower than that in a local tertiary pain clinic sample.The finding that none of the appraisal variables were significantlyassociated with one another suggests that these constructs are in-deed independent, rather than facets of one overarching concept.This supports the suggestion previously made that they shouldbe studied concurrently in order to understand their independentand combined impact upon outcomes such as mood and disability(Wollaars et al., 2007).

Many relationships were as expected, based upon otherchronic pain populations: pain catastrophizing was signifi-cantly associated with usual pain intensity, mood and paininterference; the relationship between pain catastrophizingand physical function was inverse, as expected, with the lackof statistical significance in this relationship perhaps due toinadequate sample size given the number of statistical testsbeing conducted. Whether the catastrophizing responsesmeasured are particular to pain, or perhaps reflect a moredispositional trait influencing responses to the SCI itselfand other complications of it, is an issue that should beexamined in further work (Sullivan et al., 2001; Turnerand Aaron, 2001).

As in other studies, SCI variables that had been hypothesized tobe related to psychological distress also had strong associationswith measures of mood, with SCI acceptance and self-efficacy bothsignificantly negatively associated with depression, and the latteralso with anxiety. In addition, SCI self-efficacy appeared to haveimportant relationships with pain and physical function; this re-flects the recent findings (Middleton et al., 2007) that levels of bothpain and SCI self-efficacy separately influence quality of life, andthat together presence of pain and low SCI self-efficacy appear tohave a synergistic relationship which results in further suppressedquality of life.

516 K. Nicholson Perry et al. / European Journal of Pain 13 (2009) 511–517

4.3. Clinical implications

Based upon the findings of this study, pain catastrophizing andSCI self-efficacy may both have potential as modifiable targetsamong those with pain in the rehabilitation phase. Given this,some of the early intervention models developed in other pain con-ditions (Linton et al., 2000, 2002, 2005; Boersma and Linton, 2005,2006) may be found to be applicable to this group also and thelengthy periods of time spent in hospital or other rehabilitationfacilities following injury offers an opportunity to provide suchinterventions.

4.4. Limitations

There are clearly limitations with the current study. It is cross-sectional and self-report in nature and this both introduces poten-tial response biases and restricts the ability to make causal attribu-tions. The low participation rate (45%) is a cause for concern,although it is not unlike that reported in other studies of this pop-ulation (Widerstrom-Noga, 1999; Jensen et al., 2005, 2007). Thestudy is further constrained by the relatively low numbers of par-ticipants, which restricted the use of more powerful multivariatestatistics. In addition, the small sample size and selection of partic-ipants from only one service restricts the ability to generalize thefindings. The low prevalence of this condition makes it a challengeto recruit adequate sample sizes within the time scale of most re-search projects, particularly in a country with a relatively smallpopulation.

Some aspects of the biopsychosocial models of pain are not rep-resented in the study. Pain self-efficacy and specific pain copingstrategies, as well as general behavioural coping strategies, werenot studied in this group and should be included for completeness.

4.5. Conclusions

An important aspect of this study is that it has specificallyexamined some of the elements of the biopsychosocial models ofpain and SCI in the early stages of rehabilitation following an SCI,and such data have not previously been reported in the literature.Observing robust associations between usual pain intensity, paincatastrophizing and psychological distress among this sample sug-gests that there is merit in continuing to explore these relation-ships. In addition, those in this sample with clinically significantpain, consistent with the level reported by pain clinic samples, re-ported levels of pain catastrophizing consistent with that seen insuch pain services, and levels of psychological distress consistentwith probable anxiety. The differences observed in SCI self-efficacyin those with and without pain suggest that this variable is also ofimportance. It may be reasonable, therefore, to consider a combi-nation of severe pain, lower levels of SCI self-efficacy and higherlevels of pain catastrophizing as a potentially risky combinationfor long-term outcomes in those with SCI-related chronic pain. Thismay offer a fruitful target for further research. Longitudinal studieswith larger sample sizes are necessary to test causal relationshipsbetween the variables and to more thoroughly investigate an inte-grated biopsychosocial model of responses to SCI that properlyconsiders the range of complications experienced as a result of thisinjury.

Acknowledgements

This study was funded by a PhD scholarship award to the firstauthor from the Australian Pain Relief Association/Australian PainSociety. Special thanks are extended to the staff and clients of theMoorong Spinal Injury Unit, Royal Rehabilitation Centre Sydney,especially Annalisa Dezarnaulds, Clinical Psychologist.

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