RESNA 27th International Annual Confence

Technology & Disability: Research, Design, Practice & Policy

June 18 to June 22, 2004
Orlando, Florida

The Relationship between Pain, Fatigue and Level of Depression in Wheelchair Users.

Ana Allegretti, OTR/L, Shirley Fitzgerald, PhD,
Rory Cooper, PhD, Diane Collins PhD,
Stephanie Martin, BS.
Departments of Rehabilitation Science and Technology, Physical Medicine and Rehabilitation,
University of Pittsburgh, Pittsburgh, PA
Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA


The purpose of this study was to investigate the co-morbid factors of pain and fatigue, and establish a correlation between these factors, and level of depression. The results showed a positive relationship between sensory pain and total pain (r= .99), depression and total pain (r = .49), affective pain and depression (r = .44) and affective pain and sensory pain (r= .59). Therefore, pain, depression, and disability were significantly correlated with one to another. These findings may provide insight into the relationship between depression and pain. Further research studies are essential to encourage further advancement of this field, and the development of useful and practical solutions to modify the risk factors impacting the quality of life of those who use wheelchairs.


pain; fatigue; depression; wheelchair users.


Over the past 25 years, the United States has experienced a steady decline in the age-adjusted death toll from cardiovascular disease (CVD), primarily in mortality from coronary heart disease and stroke. By making positive lifestyle changes, the American public is responsible for this decline in heart disease and stroke (1). People with disabilities share high-risk traits with the general population. For example, CVD is the leading cause of death for individuals with disabilities, with death occurring at a younger age for those with disabilities than the general population (1, 2). For individuals surviving more than 30 years after Spinal Cord Injury (SCI), CVD is the leading cause of death (2).

Co-morbid chronic conditions, such as obesity or pain, ultimately affect functional performance. For individuals who use wheelchairs, morbid obesity may complicate their care (1). Morbid obesity is estimate to affect 24.9% of people with disabilities (3) and 14% to 94% of individuals who use wheelchairs experience pain (4). Researchers have focused not only on the clinical manifestations of pain, but also on how pain influences psychosocial factors for the individual with SCI including increased incidence of depression, stress, and sleep disorders.

Fatigue is another factor that limits performance of activities of daily living (5). A common complaint, fatigue may be a symptom of a variety of medical and psychological conditions. A longitudinal study of nearly 300 British survivors of spinal cord injuries who had been living with spinal cord injuries for over 23 years, found that more than half reported exhaustion and other fatigue-related symptoms. They also tended to have higher-level spinal cord injuries and to be smokers; women appeared to be at greater risk for fatigue. Self-reported fatigue predicted other future problems, and past fatigue was linked to depression as well as a decreased sense of well-being and life satisfaction. For those with paraplegia, fatigue predicted future upper arm and shoulder pain as well as the need for both more durable medical equipment and more physical assistance from others (5).

Depression experienced by persons with SCI who reside in the community has been found to be related to social and occupational handicaps (i.e., decreased productivity and participation in self-care activities) (6). In a longitudinal study assessment of medical illness, depression and disability, a sample of 671 older patients who received inpatient treatment for depression was evaluated at entry into the hospital and 3 months after discharge. As a result, physical disability and the total number of medical illnesses were significantly related to change in depressive symptoms. Therefore certain somatic disorders may play a role in the treatment response of late-life depression and suggest that the effect of specific illnesses on depression may be mediated by the presence of functional disability (7).

Regardless, limited research has examined lifestyle factors of co-morbid disease in populations with disability; the objective of this paper is to investigate the relationship between fatigue, pain and level of depression in wheelchair users. Pain and fatigue, pain and depression and depression and fatigue are hypothesized to positively correlated.



Thirty-five subjects, who participated in the National Veterans Wheelchair Games (NVWG), held in Long Beach California, July 2003, participated in this study. The sample consisted of 30 males and 5 females, with a mean age of 51.7 years ( ± 11.2 years). The primary diagnosis included SCI, multiple sclerosis (MS), and post polio and Ehlesr-Danlos syndromes. The NVWG is a multi-event sports and rehabilitation program for military veterans who use wheelchairs for sport competitions due to spinal cord injuries, amputations, or other neurological problems. Attracting more than 500 athletes each year, the NVWG is the largest annual wheelchair sports event in the world (8).


Once the subject agreed to participate, the consent form was signed and a questionnaire was completed, which addressed several areas of interest: Demographic characteristics (i.e., age, ethnicity, disability, etc), Pain, Fatigue Severity Scale and Center for Epidemiologic Studies Depression Scale (CES-D).

The McGill's Short Form Pain questionnaire was used to determine the level of pain the subject may experience. The short-form Mc-Gill Pain Questionnaire divides pain in three different categories: sensory pain, affective pain and total pain. The sensory pain describes sensory qualities such as, temporal, spatial, pressure, and thermal; the affective pain qualities are tension, fear, and autonomic responses (changes in heart rate, body temperature, the blood pressure, etc); and the total pain describes the overall intensity of the pain experienced (9). The Fatigue Severity Scale measures the impact of fatigue on daily function, using a Likert-type rating scale from 1 to 7, with a larger score indicating more impairment (10). The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20-item scale answered on a 4-point scale from 0 to 3 (11).

Statistical Analysis:

Frequencies of all data were examined. Means and standard deviations were calculated for continuous variables. The Pearson and Spearman rho correlations were used to analyze the data based on the type of distribution.


Table 1


Total Pain

Affective Pain

Sensory Pain


p= .146
r= .25

p= .05
r= .33

p= .33
r= .17


p= .003*
r= .49

p= .008*
r= .44

p= .005*
r= .47

* Correlation is significant at the 0.01 level (2-tailed)

Mean values of CES-D is 8.38 ( ± 9.34); the Fatigue Severity Scale is 3.16 ( ± 1.54); the Affective Pain is1.06 ( ± 1.86); the Sensory Pain is 10.26 ( ± 7.94); and the Total Pain is11.31 ( ± 9.09). The results indicated a significant positive correlation between all pain scales and depression, with higher pain resulting in increased level of depression. Fatigue was significantly related to increased affective pain and a borderline correlation to depression (r=0.05). Affective, Sensory and Total pain were significantly correlated, but this relationship was expected, as these scores are part of the same scale.


Results from this analysis suggest that a relationship exists between affective pain and depression; an individual with higher levels of tension, fear, and autonomic responses he/she will have higher levels of depression. A relationship was also discovered between total pain and depression; an individual with an overall higher intensity of pain is more likely to be depressed. Affective pain and sensory pain was related as well; again this relationship was expected that these pain scores are inter-correlated in the short-form McGill Pain Questionnaire. These findings may provide insight into the relationship between pain and level of depression. A person in pain has little energy or motivation to engage in other activities, and level of pain will therefore negatively affect his/her lifestyle.


Our findings indicate that pain may affect level of depression. Future studies are needed to determine if fatigue or other co-morbid conditions also affect the level of depression. Future research would also encourage the development of useful and practical solutions to modify the risk factors thereby improving the quality of life of individuals who use wheelchairs.


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