Neuropathic Pain Experiences of Spinal Cord Injury Patients

Abstract

Background: 

Neuropathic pain (NP) is a common, severe problem that affects spinal cord injury (SCI) patients. Only SCI patients truly understand the impact and extent of this type of pain.

Purpose: 

The aim of this study was to understand the NP experienced by SCI patients and the influence of this type of pain on their daily life.

Method: 

A qualitative design was used. An interview guide including a semistructured questionnaire and in-depth interviews was conducted with SCI patients with NP in a neurorehabilitation department at a medical center in northern Taiwan. The data were collected using a purposive sampling method. Content analysis was performed on the interview data, which were obtained from 13 SCI patients with NP.

Results: 

Three themes and eight subthemes were identified that described the NP experience of the participants and the influence of NP on their daily life. The three themes included elusive pain (changing and individual pain sensations, erratically haunting threat, and phantom limb sensations), complicated feelings about pain (converting depression into an active attitude toward life, having feelings of anticipation and anxiety about future pain relief, and facing and experiencing pain), and renewed hope (bravely fighting pain and seeking pain relief methods).

Conclusions: 

This study revealed three important themes of NP experienced by SCI patients, including elusive pain, complicated feelings about pain, and renewed hope. Nurses should understand the nature of NP, provide a thorough pain assessment, and design a proper pain management plan to care effectively for patients with NP.

Introduction

The prevalence of neuropathic pain (NP) in patients with a spinal cord injury (SCI) ranges from 18% to 96% (^{Hagen & Rekand, 2015}; ^{van Gorp, Kessels, Joosten, van Kleef, & Patijn, 2015}). NP is the most challenging type of pain to manage (^{Cohen & Mao, 2014}; ^{D’Angelo et al., 2013}). This type of pain has a severely negative influence on the quality of life of 67%–72% of SCI patients (^{Ataoglu et al., 2013}; ^{van Gorp et al., 2015}). Approximately 70%–80% of SCI patients experience pain, with approximately 33% of these experiencing unbearable pain (^{Teixeira et al., 2013}). For SCI patients, managing pain is more challenging than any walking disability or sexual, bladder, or bowel dysfunction (^{Hagen & Rekand, 2015}). Previous studies have indicated that 33% of SCI patients would rather have an injured spinal cord than experience NP (^{Teixeira et al., 2013}). NP is often treated with pain medications. However, not all pain killers are effective in relieving NP. In addition, pain treatment may cause side effects, which commonly include nausea, constipation, and sedation. A combination of pharmacological and nonpharmacological pain therapy may achieve a moderate improvement in NP (^{Attal et al., 2010}; ^{D’Angelo et al., 2013}; ^{Siddall, 2009}). However, NP in SCI patients remains poorly understood, and it is easy for nonsufferers to overlook the effects of this type of pain. Patients who frequently experience severe pain face a high risk of depression. This study used a qualitative research method to explore and understand NP in SCI patients. The results have the potential to improve the quality of nursing care by raising the awareness of nurses to the pain that their patients experience.

Literature Review

SCIs typically result from a substantial external force that fractures or dislocates the vertebrae. In Taiwan, approximately 41,586 patients have an SCI, and this number increases by approximately 4,500 each year (^{Spinal Cord Injury Foundation, 2016}). Traffic accidents are the main cause of SCIs. Approximately 66% of SCI patients are 20–49 years old, 69% have paraplegia, and 92% are confined to a wheelchair for the remainder of their life (^{Chiu et al., 2010}; ^{Lee, Cripps, Fitzharris, & Wing, 2014}). SCI often results in severe disabilities. The spinal cord consists of 8 pairs of cervical nerves (C1–C8), 12 pairs of thoracic nerves (T1–T12), 5 pairs of lumbar nerves (L1–L5), and 5 pairs of sacral nerves (S1–S5). Tetraplegic patients have varying degrees of upper limb involvement. Paraplegia refers to damage to the thoracic, lumbar, and sacral spine. Injury results in impaired function of the lower extremities and/or pelvic organs, depending on the level of the lesion. Paraplegic patients experience leg paralysis and some trunk involvement. Tetraplegia refers to damage to the cervical spine resulting in impaired function in all four extremities as well as in the trunk and pelvic organs. Patients with T1 or C8 injuries will have impaired fine finger control, making self-care more difficult and requiring caregiver help with activities of daily living (^{McLean, 2013}). Improvements in medicine have increased the life expectancy of SCI patients considerably. In addition to long-term disability, SCI patients also experience complications such as pain, weakness, and fatigue, all of which considerably and negatively affect social functions and mental health (^{Sezer, Akkus, & Ugurlu, 2015}). After an SCI, although damaged nerves lose normal control over bodily functions, they continue sending messages to the brain (^{Finnerup, 2013}). Pain is described by SCI patients as the worst problem that they have ever experienced. NP is one of the most challenging problems after SCI and affects quality of life (^{D’Angelo et al., 2013}).

NP is defined as “pain caused by a lesion or disease of the somatosensory nervous system” (^{International Association for the Study of Pain, 2014}). Injured neurons trigger a series of mutually related events in the spinal cord. Inflammatory (cytokines, prostaglandins) and neuromodulator (glutamate, gamma-amino butyric acid [GABA], serotonergic) agents change their expression and function. Microglia and astrocytes are activated, enhancing neuron firing after stimulation, changing spinal neuron function, and resulting in pain. Generally, patients feel spontaneous pain and evoked pain (^{Cohen & Mao, 2014}; ^{D’Angelo et al., 2013}). Allodynia, one characteristic of NP, may cause a pain response due to stimuli that typically would not cause pain (^{Finnerup, 2013}). For example, feeling sunlight on the skin, walking, and getting dressed may cause severe pain. Patients often describe NP as a sharp, shooting, electric, burning, and stabbing feeling (^{Baron, Binder, & Wasner, 2010}; ^{Nakipoglu-Yuzer, Atci, & Ozgirgin, 2013}). More than 50% of SCI patients experience pain because of sedentariness, infection, fatigue, muscle cramps, cold weather, and sudden movement (^{Hagen & Rekand, 2015}).

The management of NP usually includes medications such as neurontin, nortriptyline, and amitriptyline. Although these medications may effectively lessen the intensity and frequency of pain, they have not been shown to improve feelings of coldness, itchiness, sensitivity, and dullness and have been associated with side effects, including weakness, edema, dizziness, and somnolence (^{Snedecor et al., 2013}). Other treatments that may also be effective include transcutaneous electrical nerve stimulation, nerve block, surgical ablation, and spinal cord stimulation. However, long-term effects for these treatments have not been maintained (^{Hagen & Rekand, 2015}).

Pain often persists after the original injury has healed. Although this pain cannot be alleviated using standard drugs, it may be palliated using antidepressants or anticonvulsants (^{Teasell et al., 2010}). People often believe that the symptoms of NP are caused by psychological factors and that the true cause of NP is often overlooked. When people experience pain and others believe that the pain is imagined, then the affected people tend to feel stressed, which may further exacerbate the pain (^{Cohen & Mao, 2014}). Thus, when someone indicates that he or she is feeling pain, these complaints should be taken seriously.

Previous studies have reported higher rates of depression and attempted suicide (^{Gwak & Hulsebosch, 2011}) and reduced quality of life (^{Ataoglu et al., 2013}; ^{van Gorp et al., 2015}) among SCI patients who experience chronic pain. SCI patients must learn how to live with a disability for the rest of their lives. Pain and disability increase the likelihood of facing multiple challenges at each stage of life.

Methods

The purpose of this study was to better understand the NP that is experienced by SCI patients. This qualitative study used semistructured interviews to collect data.

Research Design

A qualitative research design was used to recruit SCI patients with NP and to gather information on the subjective aspects of their NP. Recruiting took place between November 2009 and May 2010 at a teaching hospital in Taipei, Taiwan. A semistructured interview that was composed of the following questions was used to guide the interview process: (a) “Please point to the location of your pain”; (b) “Please describe how the pain feels and share your experience”; (c) “Please state how the pain influences you”; (d) “Have you used any strategies to stop the pain? Please explain”; (e) “Have you used any strategies to live with the pain? Please explain”; and (f) “What makes the pain worse?” Before the interview process, a pilot study was performed to confirm the appropriateness of these interview questions.

Participants

A purposive sampling method with an in-depth interview process was adopted. Patients who met the following were recruited as participants: (a) having experienced a traumatic SCI and experienced NP; (b) aged ≥ 18 years, able to speak Mandarin, and willing to be interviewed; and (c) having experienced various levels of motor and sensory impairment and paralysis due to an acute traumatic SCI. The recruitment process ended when new participants did not add new information, indicating data saturation. The exclusion criteria included brain trauma, ventilator or oxygen dependence, psychiatric disorders, suicidal trauma, cognitive deficits, and major chronic illness.

Data Collection and Analysis

In this study, an experienced specialist nurse assessed the pain of the recruited patients and referred only those who met the inclusion criteria and agreed to participate. Before beginning the interview, the researcher explained the subject area, obtained consent, and talked to the participants. Written information describing the purpose and process of the study, including a detailed overview of participants’ rights and the security of their identities, was supplied to participants during the recruitment process, and written consent was obtained from all participants. Consultations were conducted in private locations that were acceptable to the participants.

The data were collected through face-to-face, audio-recorded interviews that lasted between 40 and 125 minutes (average = approximately 60 minutes). Each participant was interviewed once. The interviews took place without visitors and while at rest in the participants’ wards. All of the interviews were transcribed verbatim by the first author. The researchers collected data until saturation was achieved.

The audio recordings of each interview were transcribed verbatim by the first author immediately after the completion of each interview. The typed transcripts were carefully checked using multiple relistenings of the recordings. The interview text was then read and understood independently. Each of the participants’ descriptions were then compared and discussed with respect to the intention of each research question. The texts were then split into meaning units that appeared to share the same content and then classified into categories that were inspired by the units. Each author cross-checked the analysis carefully to ascertain the accuracy of the emerging categories. Finally, the complete data set was categorized, and relationships among the categories were used to conceptualize the information into themes.

Ethical Considerations

This study was approved by the institutional review board at the Taipei Veterans General Hospital (Institutional review board no. 98-02-50A). Patients who met the recruitment criteria and who agreed to participate were recommended to the researcher. Informed consent was obtained from all of the participants before conducting the interviews. The participants were free to withdraw from the study at any time, and their reasons for refusal were noted.

Rigor

The trustworthiness of the qualitative research was determined based on the criteria proposed by ^{Lincoln and Guba (1985)}, who used credibility, transferability, dependability, and confirmability as the effective criteria to show rigor in qualitative research. In this work, a senior nurse who had cared for SCI patients for more than 10 years assessed the pain of patients and referred to the researchers only those who met the inclusion criteria and agreed to participate. A comfortable and private setting was used for each interview. This approach helped establish trust between the participants and the researcher. In-depth and open-ended interviews were used to verify the true feelings of participants regarding their NP and to establish credibility. The second author, who had been trained in qualitative interviewing, had taught advanced qualitative research, and had published over 10 qualitative studies in international journals, conducted all of the interviews to maintain consistency. The descriptions provided by participants elucidated the influence that pain had on their daily lives. Each interview was audio recorded, and the interviewer also took notes. Throughout the process, the researcher communicated constantly with the qualitative research scholars about the data analysis to establish transferability. All of the interviews gathered thick descriptions from the participants, showing the complete context. The qualitative research scholars were invited to cross-examine the interview process, and the verbatim text was used to enhance the dependability of findings. All of the interviews were properly preserved to allow for checking and rechecking of the data throughout the study to establish confirmability.

Results

This study was conducted to elucidate the NP experienced by SCI patients as well as the influence it had on their daily lives.

Demographic Information

Fifteen patients agreed to participate in this study. However, two could not be interviewed because of the severity of their pain. Therefore, only 13 patients were interviewed. Twelve of the participants (92%) were men, and the age range of the participants was between 22 and 57 years (mean age = 41.98 years). Most of the primary caregivers were foreign workers (62%). Two thirds (62%) of the participants had received their SCI because of a traffic accident, and 31% had received their SCI because of an elevated fall. Approximately 66% were tetraplegic, and 33% were paraplegic. The period of injury was between 6 and 74 months (mean = 21.36 months).

Neuropathic Pain Experience

The participants typically experienced NP for no apparent reason and typically described their pain as a long-term disturbing symptom that they are required to handle by themselves. The NP experience of patients and their views about pain are summarized into three themes and eight subthemes (Table 1). The three main themes are elusive pain, complicated feelings about pain, and renewed hope.

TABLE 1.: Themes and Subthemes Regarding the NP Experienced by SCI Patients

Elusive pain

Pain is a subjective experience. Pain typically disappears after an illness is cured or when the patient takes an analgesic. However, SCI patients often experience NP for prolonged periods. NP is obstinate and differs from other types of pain. When asked to describe their feelings about NP, the participants indicated that it is difficult to describe. Although they had no actual physical sensation in certain body parts, they reported often feeling tingling sensations and pain in these parts. The following three subthemes were identified: changing and individual pain sensations, erratically haunting threat, and phantom limb sensations.

1. Changing and individual pain sensations

SCIs often cause sensory and motor dysfunction. In addition to affecting daily life functions, body parts governed by the damaged nerves may lose sensation or generate feelings of pain when touched lightly. Abnormal sensations are another characteristic of NP. The participants presented varying descriptions of such sensations.

Other people experience a tingling but I have felt only numbness. Others have described feeling like ants are biting them or a tingling sensation, but I have not experienced such sensations. People cannot understand how I feel if they have not experienced the pain. Sometimes, the pain is like lightning shooting up from my feet. Initially, my body felt tight, as if I was wearing a mini skirt or like I was wrapped up like a mummy. My sensations change from time to time. (Patient 2)

My hands sometimes feel cold and my legs sometimes feel warm. It felt as if I put my hands in a refrigerator. It comes suddenly and continues for a while and then disappears. (Patient 6)

I cannot feel temperature or heat sensations on the left side of my body; it is as if I have been cut in half. (Patient 13)

2. Erratically haunting threat

Pain sensations are caused by sensory information that is transmitted in the body. The NP experienced by the participants in this study was persistent, indicating that signals were being passed constantly between the nerves and the brain. The conditions of some patients may gradually improve. Pain may be aggravated by weather changes, and the degree of pain changes according to the activities undertaken.

The weather is a major factor; our bodies are very sensitive to the weather. We feel more pain in the winter because our nerves are very sensitive. In the summer, air conditioners also make us feel uncomfortable, and we often need a blanket. When we change our posture to an uncomfortable position, we feel more pain. (Patient 4)

I feel severe pain when I just wake up…. I feel throbbing pain from time to time…. I also feel pain when the weather changes. (Patient 11)

In this study, 11 of the participants indicated that they felt more pain when the weather changed. In addition, 10 of the participants indicated that coldness caused pain, 9 felt more severe pain when getting up in the morning, and 7 expressed that touch could cause pain.

3. Phantom limb sensations

Damage to the nervous system may cause abnormal activation of the nervous system. Damaged nerves may be extremely sensitive, and patients may intermittently experience a strong prickling sensation, a sense of shock, or sensations of pain or burning. These sensations affected the daily lives of participants, often leaving them feeling exhausted and miserable. One described the sensations as follows:

I felt numbness and prickling throughout my body.... However, when you touched it, I could not feel anything at all…. I do not know why I felt numbness and prickling.... I do not know how to describe it...my body simply feels painful...the feeling is always with me. (Patient 9)

Complicated feelings about pain

The brain continues to receive messages that signal discomfort, and the body cannot resist these uncomfortable feelings. Patients who experience long-term pain and physical disability often feel depressed and emotionally compromised, which often leads to a contradictory complex that encompasses the following three subthemes: converting depression into an active attitude toward life, having feelings of anticipation and anxiety about future pain relief, and facing and experiencing pain.

1. Converting depression into an active attitude toward life

Because of the long-term pain and physical disability that are associated with SCIs, SCI patients initially experience a considerable amount of fear of pain and disability. Consequently, they often feel depressed or even attempt suicide. However, they must overcome their depression. For example, Patient 3 stated the following:

I often feel great pain; sometimes, I cannot bear the pain and wish to die.

My husband told me that my children need me…. I think I should strive to live. However, when I feel extremely uncomfortable, I really wish to end my life.... The problem is how to end my own life...Because so many people care about me, I do not want to die.... I am lucky; my children are sweet...some people in the community are more miserable than we are...in addition, my friends treat me positively. (Patient 2)

2. Having feelings of anticipation and anxiety about future pain relief

Although SCI patients must tolerate their pain and learn to live with it for the remainder of their lives, they hold out hope that improvements in medical technologies may one day offer a cure. When asked about strategies that they used to live with the pain, some of the participants responded as follows:

I want to keep myself in an optimal condition. Because medical technology continues to improve, I will have a chance when new drugs are developed…. If I do not have excellent physical strength, then no drug can help me. (Patient 2)

I wonder whether neurotin can cure my numbness and prickling sensations and damaged nerves.... The young girl next to my bed began to walk after only one injection of nerve growth factor. (Patient 11)

3. Facing and experiencing pain

NP is a type of chronic pain. Because of the long-term nature of the pain, some patients consider it to be a part of their body and learn to live with it.

The pain seems to have become a part of my body.... I live in harmony with it.... After one year, I stopped taking medicine because it caused incontinence.... Although I have stopped taking the medicine, I can live in harmony with the pain. (Patient 5)

I tried to bear the pain by myself and did not tell my family members about it because they were also having a hard time. The injury I experienced has affected my family members, so I did not tell them about my pain...my family members often worry about me...when they ask, I tell them that I am fine. (Patient 8)

Previously, I bore the pain. Now, I often go out even if I am feeling pain. I simply ignore it. (Patient 7)

Renewed hope

Patients with NP must manage long-term chronic pain. General pain may be relieved using antidepressants, relaxation therapy, or analgesics. However, opioid analgesics are ineffective in relieving NP. Therefore, patients with NP should adjust their mood and change their attitude toward the pain to enable them to tolerate a higher degree of pain. Some of the participants continued to feel pain but reported that they did not suffer from it. The two subthemes are as follows: bravely fighting pain and seeking pain relief methods.

1. Bravely fighting pain

Patients with NP typically experience pain for a long period and often try various types of analgesics, antidepressants, and antiepileptic drugs. However, they still need to bear the pain and drug side effects. Therefore, many of the participants had decided not to take their medicine.

I do not take medicine…. I often bear the pain, and finally, I accepted the pain…. Medicine can be addictive. I do not want to rely on medicine, and I think I should bear the pain. (Patient 3)

I sometimes cannot sleep because of the pain; sometimes, I want to cry because of the pain…. I still feel pain now, but I do whatever I like, such as eating, sleeping, and playing…. Previously, I did not go out with people, but now, I will. I will not feel less pain if I cry. (Patient 7)

2. Seeking pain relief methods

Numerous methods for pain relief include medicine, massages, shiatsu, slapping, acupuncture, and exercise. However, there is no method that is effective for all participants. Patients often seek spiritual sustenance by singing, reciting Buddhist sutras, chatting with friends, and other methods rather than attempting to cure physical pain. The participants in this study reported trying various methods to relieve and live with their pain.

Patient 11 stated: “This hospital is my only hope and that is why I came here.” He actively performed rehabilitation exercises and was highly concerned about his condition, particularly the numbness and prickling sensations he experienced. He said “I took medicine recommended by my physiotherapist to relieve my pain, but I still feel pain. I do not know what type of medicine can help me.”

Another participant described the following methods of pain relief:

I like to chat with friends…. It helps me forget about my pain…. Drinking coffee and chatting with friends make me happy. (Patient 1)

I sing because I can forget about my pain by remembering and thinking about the lyrics…. Having a glass of wine can help me sleep and forget about the pain…. I cannot ask my husband to talk to me or telephone my friends at midnight…. I often feel sad at midnight…. When [this happens] I pray to Buddha or listen to music. (Patient 2)

Praying to Buddha is useful…. having Buddha in my mind makes me feel optimistic…. (Patient 12)

As no one method is universally effective, the participants tried various methods to relieve their pain. Several participants described methods for managing their pain: “I feel that taking a bath is useful and helps me relax. The water temperature should not be too high; hot water may scald my skin, which doesn’t have any feeling.” (Patient 4) and “Massaging the right spots can rapidly relieve my pain” (Patient 10).

Most SCI patients are unable to accept immediately the reality of their dramatic life changes. Some of the participants actively sought treatment methods and heeded the advice of friends and family on pain relief, whereas others turned to religion for relief. Over time, the participants attempted to live with their pain. Some indicated that they considered their pain to be a part of their body and refused to take medicine because of the side effects. Although the participants ultimately adapted to their pain, they remained hopeful that improvements in medical technology may offer new methods to relieve NP.

Discussion

This study was conducted to understand the NP that is experienced by patients with SCIs. NP is considered one of the most severe types of pain (^{Cohen & Mao, 2014}). The participants continued feeling pain after the original injury had healed. Thus, physical factors alone cannot explain this pain (^{Baron et al., 2010}; ^{D’Angelo et al., 2013}; ^{Radu et al., 2013}; ^{van Gorp et al., 2015}). Qualitative research allows patients to fully describe their experiences and express their feelings, allowing their perceived pain to be understood. In this study, three themes and eight subthemes were proposed to describe the NP experience of SCI patients and to reflect on the influence of pain on their daily lives.

Nature and Responses of Neuropathic Pain

The participants typically experienced NP for a prolonged period and described their pain as elusive and unpredictable. The NP descriptions of each participant were unique. People without NP cannot understand this type of pain. This finding echoes the results of a previous study that reported the existence of a gap between received treatments and patient perceptions of their pain (^{Hearn, Cotter, Fine, & Finlay, 2015}). ^{Nakipoglu-Yuzer et al. (2013)} showed that the perceived NP of SCI patients changes often and that the types of pain that they experience include burning pain, shooting pain, soreness, and prickling. The pain may occur spontaneously or in response to stimuli (^{Baron et al., 2010}; ^{Nakipoglu-Yuzer et al., 2013}). Moreover, body movements and environmental factors may aggravate the pain. The patterns of pain varied among the participants in this study. The results of this study agree with those reported by ^{Baron et al. (2010)}, who indicated that touch and weather changes may cause pain. A study in Sweden of SCI patients with NP (^{Lofgren & Norrbrink, 2012}) found that pain was their main problem. Nurses typically observe the behavior of patients to assess their pain but seldom listen to patient self-descriptions of their pain. If they detect no physiological change, nurses often do not consider a patient to be in pain (^{Morgan, 2014}). Clinical nurses should pay attention and work to understand the nature of NP in SCI patients. Knowledge about the pain characteristics of this patient group may provide correct and instant pain assessment and intervention.

Most of the participants in this study indicated that NP caused complicated feelings that made them depressed and consider suicide. ^{Teixeira et al. (2013)} indicated that SCI-related symptoms typically increase in severity over time. This type of pain is difficult for patients to describe, and many patients believe that they are the only ones who are able to accurately perceive and understand their pain. ^{Buscemi, Cassidy, Kilbride, and Reynolds (2017)} investigated the feelings of patients who experienced long-term pain and found that participants perceived the impact of NP in everyday life to be underestimated by healthcare practitioners. ^{Widerström-Noga et al. (2017)} found that participants rarely discussed their pain because they wanted to avoid bothering other people. In addition, Buscemi et al. established that the participants felt that healthcare professionals were too busy to help relieve their pain. Therefore, in light of the complexity of NP pain issues and the difficulties that medical personnel face in understanding or managing this type of pain, nurses should focus additional efforts to care for the lives and emotional state of their SCI patients and assist to alleviate their depression and negative emotions. Concern, support, and encouragement are factors that are known to increase patient well-being.

Self-Management of Neuropathic Pain

Although some drugs may be used to treat the NP of SCI patients, these drugs are generally ineffective and may cause severe side effects (^{D’Angelo et al., 2013}; ^{Finnerup, 2013}). In this study, the participants avoided taking analgesics because of side effects such as weakness, dizziness, somnolence, and addiction. ^{Hagen and Rekand (2015)} noted that medication has limited effects on SCI NP. The participants in this study used massage, acupuncture, exercise, and physical therapy for pain relief more often than opioids. This finding agrees with those of ^{Lofgren and Norrbrink (2012)} and ^{Baron et al. (2010)}. NP after SCI is difficult to treat successfully. Some of the participants used complementary treatments regularly to relieve pain. Complementary treatments should be an important component of successful NP management.

Mindfulness

Mindfulness may be a useful tool for the participants in this study. The efficacy of mindfulness has a well-documented base of evidence in terms of helping reduce or avoid medication use (^{Garland et al., 2014}). In this study, some participants relied on spiritual sustenance, although it is likely that their pain will never be cured. To distract themselves from their pain, they sang, recited Buddhist sutras, and chatted with friends. These activities put them in a more positive mood to face their pain, and they endeavored to live with their pain. This finding echoes the results of ^{Lofgren and Norrbrink (2012)}, who found that watching TV, listening to the radio, working, being physically active, and meeting friends helped distract individuals from focusing on or thinking about their pain.

Conclusions and Implications for Practice

This study explored factors affecting SCI patients with NP. The study findings indicate that NP is located at multiple sites and that patients are not able to describe their pain fully. Patients often feel depressed or even attempt suicide. However, they must overcome their depression. They require strong support from their families, friends, and clinical staff. Pain management was an important focus of this study. Patients with NP after SCI were able to endure long-term pain. During the early stage of injury, participants were often in despair because of their pain and disability. However, over time, they were encouraged by their family members and friends to adjust and to learn to live with their pain (^{Norrbrink & Lofgren, 2016}). Mutual support and encouragement among patients were also found to be an effective form of support. ^{Lofgren and Norrbrink (2012)} examined the knowledge, experience, and treatment wishes of patients, finding that most patients were reluctant to use pain-relieving drugs and often required complementary treatments and knowledge regarding how to live with their pain. Patients expressed that complementary treatments were helpful for pain management. They desired their health professionals to be knowledgeable about and interested in their pain (^{Norrbrink & Lofgren, 2016}). Similarly, the participants in this study accepted the pain but still sought pain relief methods. Our participants with SCI and NP did not want to bother their family. For this reason, we recommend that health professionals should obtain knowledge about the clinical characteristics of pain in this patient group, listen to the experience of their patients, and improve pain management based on patient needs.

Although data saturation was achieved, participants were limited to one teaching hospital in northern Taiwan. In addition, two patients could not be interviewed, with one not willing to talk because of a bad mood and the other not willing to talk because of severe pain that led to his wife refusing our visit. We could not observe their response to pain or collect data from their caregivers to understand how the pain affected these two cases. We recommend that future studies collect data from multiple hospitals to increase the richness of the information acquired and systematic methods should be employed to effectively assess the pain of patients and to explore the effect of pharmaceutical and nonpharmaceutical methods on the treatment of NP. Clinical staff have an important role to play in relieving the NP of SCI patients and in gradually helping these patients learn to manage their pain more effectively.