create the summary of the findings"MATERIALS AND METHODS
The participants were individuals with SCI referred to Brain and Spinal Cord
Injury Research Center (BASIR), Tehran University of Medical Sciences, a
tertiary referral center for outpatient rehabilitation with patients from all over
Iran between 2012 and 2013. The inclusion criteria were as follows: persons
aged 418 years who suffered from a SCI and who were subsequently referred
to a rehabilitation center. There was no limitation with respect to co-morbid
psychiatric diseases or any other criteria. There were 140 participants including
101 men (72%) and 39 women (28%). The mean age was 29.4±7.9 years,
mean age at time of SCI was 25.5±8.3 years and the duration of SCI was
46.3±46.5 months, with a median of 29.5 months (Table 1).
Study methods
This cross-sectional study was part of a larger project approved by the Ethics
Committee of the Tehran University of Medical Sciences. The participants were
given thorough explanation of the study and written informed consent was
obtained. Further clarification was given throughout the interview as needed.
Interviews of approximately 30 min in duration were completed in the BASIR
clinic while participants were waiting for physicians or treatment providers.
Data were collected by means of structured face-to-face interviews and by
trained interviewer only from patients. Information about social support was
gathered by talking to the patients alone to avoid causing shame and to make
them respond easily. The first part of the interview comprised of demographic
and clinico-pathological questions related to age, sex, education level, marital
status, completeness of neurological injury, level of injury (tetraplegia or
paraplegia) and cause of injury.
Measures
Pain intensity. We used the Persian version of the Brief Pain Inventory24 to
measure the pain level, quality, pattern, duration and location and the degree to
which pain has affected daily activities during the past week. Scores on the Brief
Pain Inventory range from 0 to 10, with higher scores indicating greater pain
interference with respect to activities of daily living. Participants were asked to
rate their average pain intensity during the past week on a 0–10 NRS (numeric
rating scale), with 0 corresponding to ‘no pain’ and 10 indicating ‘pain as bad as
it could be’ (the worst pain the patient has ever experienced). Scores in the
range of 1–4 were considered ‘mild’ intensity, 5 and 6 represented ‘moderate’
pain and 7–10 were categorized as ‘severe’ pain intensity. Also patients were
asked to score the interference or disturbance of pain in their normal work and
activity, mood and relation with others.
Education level was divided into the following three categories: low, persons
with 0–8 years; medium, persons with 9–12 years; and high level, those with
412 years of education. Number of years was used in light of the fact that this
quantity is more easily interpreted by all readers as opposed to levels or degrees
that may vary by location or profession. Patients also asked about the
availability of appropriate facilities, such as suitable wheelchairs, urinary
catheters, anti-bedsore mattresses and diapers. We used availability of facilities
as a measure of economic situation. The participants who had all of these
amenities were categorized as good economic situation; those who had only a
wheelchair in addition to urinary catheters or diapers were categorized as
moderate economic situation; and those who had only a wheelchair and
inadequate access to diapers or urinary catheters were categorized as poor
economic situation.
Pain interferences. We included several variables to measure impairment of
general activities, including walking ability, normal work, relation with other
people and sleep. We used the above-mentioned variables based on the
previous scales including pain scale based on the visual analog scale range
from 0 to 10, with higher scores indicating greater impairment in their
activities.
Social support. Social support was measured using the Multidimensional Scale
of Perceived Social Support,25 a 12-question multiple choice inventory, to
evaluate the presence of different categories of support. Each item was scored
using a Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly
Table 1 Demographic and clinico-pathological characteristics of
participants
Median (interquartile range)
Age (years) 29.4±8.3 28 (24–32)
Age at the time of injury (years) 25.5±7.9 24 (19–30)
Duration of injury (months) 46.7±29.5 29.5 (13–61.5)
Worst pain 6.6±2.8 5–10
Least pain 3±1.2 5–10
Average pain 5±2.2 3–7
How, during the past 24 h, pain has interfered with your
Relation with other people 2.5±3.1 0–5
Mood 2.7±3.2 0–5
Walking ability 3.5±3.3 0–6
Normal work 2.3±3.1 0–5
General activities 3.6±3.3 0–6.7
Sleep 3±3.2 0–6
Sex
Male 101 (72%)
Female 39 (28%)
Marital status
Single 68 (48.9%)
Married 69 (49.6%)
Widow 1 (0.7%)
Separated 1 (0.7%)
Level of injury
Paraplegia 93 (66.4%)
Tetraplegia 47 (33.6%)
Completeness
Incomplete 72 (54.5%)
Complete 60 (45.5%)
Cause of injury
Crash injury 92 (69.2%)
Falling 27 (20.3%)
Sport injuries 5 (3.8%)
Occupational injuries 6 (4.5%)
Others 3 (2.4%)
Education level, years
0–8 45 (33.1%)
9–12 70 (51.5%)
412 21 (15.4%)
Association between pain and social support in SCI
Z Khazaeipour et al
181
Spinal Cord
agree). The source of support, with regard to responses, was further divided
into family, friends and other persons important to the patient’s social support.
Statistical analyses
Some questions were not answered by patients, so there were some missing
data; but these data were not included in analysis. SPSS software version 18
(SPSS Inc, Chicago, IL, USA) was used for statistical analysis. The distribution
of data was evaluated using the one-sample Kolmogorov–Smirnov test. Either
Student’s t-test or a Mann–Whitney test was used for analysis of continuous
variables between two groups. The association of categorical variables was
evaluated by Chi-square or Fisher’s Exact T-test as appropriate. Correlation of
continuous variables was assessed by Spearman’s correlation. Continuous
variables were presented as mean±s.d., and categorical variables were
presented as frequency (percent). The significance level was set at α⩽0.05
representing 95% confidence. Wherever data were missing, it was excluded
from analysis.
RESULTS
The response rate was 97.2% (140 out of 144). The socio-demographic
information and clinico-pathological characteristics of participants are
shown in Table 1.
Ninety-three participants were paraplegic (66.4%), and 72 had
incomplete lesions (54.5%). The most common causes of SCI were
motor vehicle crash (69.2%) and falls (20.3%). Seventy participants
had pain (50.7%), of which 79.3% had bilateral pain; the most
common site of pain was the lower limbs and back, and the least
common location was the pelvis or anus. Pain in the upper limbs was
rarely reported. The frequency of pain was greater in paraplegic
individuals compared with that in tetraplegic individuals and was
higher in individuals with incomplete SCI vs those with complete SCI,
although these relationships were not significant (Table 3). The quality
of pain was described as aching (41.4%), tingling (32.9%), pressure
(15.7%), coldness (5.7%) and electric shock sensations (4.3%). The
most common pattern of pain was ‘always’ (42.9%) and the least
common form was ‘no pattern’. The most common locations of pain
were in the knees (50%), shins (45.7%), calves (42.9%), feet (41.4%),
ankles (38.6%) and lower back (31.4%). The quality, pattern, duration
and location of pain have been shown in Table 2. The mean scores for
average pain, least pain and worst pain have been shown in Table 1.
There were no relationships observed between pain and gender,
marital status, level of injury and completeness of neurological deficit
(Table 3). There were no significant differences in mean least and
average pain between individuals with paraplegia and tetraplegia. The
mean score of worst pain in tetraplegic individuals was significantly
higher than in paraplegic individuals (4.6±3.9 vs 3.2±3.7, P=0.036).
With respect to socio-demographic factors, there was a relationship
between pain and education level and also access to facilities and
supplies. In people with SCI who had education level of 0–8 years,
pain was significantly higher than in people with SCI with education
level of 412 years (64.4% vs 57.1%) and higher than in individuals
with medium level (64.4% vs 41.4%). In other words, those with a
medium level of education had the least amount of pain. Again those
with medium level of access to facilities and supplies reported lower
frequency of having pain in comparison to two other levels (P=0.034;
Table 3).
There was no correlation between pain and age or age at the time of
SCI. Duration of SCI had a negative correlation with worst pain
(r=− 0.192, P=0.024). There was no relationship between pain and
social support. There was positive correlation between pain and
impairment of mood, normal work, relations with other people and
poor sleep habits (Po0.001; Table 4)."