A Review and Reflection of Neuropathic Pain

Posted by Nurse Linda in Life After Paralysis on August 11, 2020 # Health

Pain is different for everyone. Even though it has been qualified by pain scales, the report is the perception of pain felt by the person who has it. What is felt by one person may be rated differently by another person. No one can tell you that your pain is tolerable, not bad, or horrible. Chronic pain does not stop and can be related to depression.

There is a commercial on TV about breast cancer. The woman says it is relentless but so am I. Every time, I hear that, I think of people I know who have a spinal cord injury (SCI). They are relentless as well. Isn’t everyone when it comes to life issues? Neuropathic pain can be relentless, but you must be relentless when finding a treatment that works for you.chronic pain sign

There are different types of pain, somatic, visceral and neuropathic. Somatic pain occurs in the muscles or soft tissues. There are analgesics for muscular, headache and post injury pain such as acetaminophen and NSAIDS (nonsteroidal anti-inflammatory drugs). There are also narcotics for more severe temporary pain like the type after surgery or a broken bone. But none of these treat neuropathic pain. Narcotics will dull your mind to the feeling of pain but that is another problem created when your mind is dulled. They are also addictive, so the result is no real pain relief but an addiction problem that can develop.

Visceral pain arises from a problem in your internal organs. These can result from irritable bowel pain, pancreatitis, cancer or any difficulty with internal organ systems. Significant pain in the viscera is also typically treated with over the counter pain medication, NSAIDS to reduce inflammation, and narcotics.

Neuropathic pain is nerve pain. The nerves in the CNS (central nervous system) can be affected as in brain and spinal cord injury from disease or trauma. All the other nerves in the body are PNS (peripheral nervous system) carry messages to and from the CNS. PNS nerves can also be affected. Neuropathic pain can occur from a disturbance in the CNS or PNS or both. Neuropathic pain changes throughout the lifespan. The neuropathic pain you have today will be different over time. Occasionally, it even resolves either due to nature or from long term treatment. The source of resolution of neuropathic pain is unclear.

After a spinal cord injury, the body still works below the level of injury. It is the messages to and from the brain to the body and the body to the brain that are not getting through. Pain is the nerves attempting to get a message to the brain that something is not working correctly. You may know that you have a spinal cord injury or brain injury that is the source of the inability of the messages to be transmitted but the brain and body do not understand that. The messages keep attempting to be sent in both directions. The fact that you are noticing pain is telling you that your body is trying to work, the messages are just being miscommunicated.

The first line treatment for neuropathic pain is movement. The theory is that stretching the muscles will relax muscle tension and thereby relax the nerve that tenses the muscles. Fatigue of the muscle can make the nerve relax. Range of motion exercises using slow, gentle, repeated movement to the body provided by your moving of all your body joints or someone else doing this for you is a start. This will help more often with mild neuropathic pain. The benefit of movement is maximized when combined with other treatments.

If you are interested in other non-invasive treatments for neuropathic pain, success has been met for some by using acupuncture, biofeedback, stress reduction, hypnosis and psychotherapy. These therapies take time to produce results. Several treatments are needed but well worth the effort. Other people will try distraction as a pain reduction technique. Getting absorbed in other activities has helped many people distract from their pain.

Specifically, created medication for neuropathic pain are the drugs Neurontin and Lyrica. These drugs have helped many people. They are taken by mouth, so they work in the entire body. A very small number of people have side effects of lethargy (tiredness) and swallowing difficulty for about 8 days. Then these complications just go away. If you can tolerate the side effects for the 8 days, the benefits are great. However, if you need to increase your dose, the same side effects repeat for the same time span. It must be noted that most individuals who take Neurontin or Lyrica do not have the side effects.

Other types of medications have helped individuals with neuropathic pain. Some low dose antidepressants and anticonvulsants have been used to effectively treat neuropathic pain. The dosage of these medications is lower than for the treatment of depression or seizures. However, people with spinal cord injury who require these medications for treatment of depression or seizures do have less reports of issues with neuropathic pain.

Injections near the nerve that is causing pain can help reduce transmission of miscommunicated messages. Numbing medication is typically used. Repeated injections must be taken over time to maintain pain relief. In the past, phenol has been used to permanently destroy nerves that produce neuropathic pain. Some physicians might still deliver this treatment, however, since there are other newly developed treatments, it is not used today to maintain the use of the nerve.

Most people have heard of the baclofen pump for individuals with extreme spasticity. This is a surgically implanted device that is filled with high levels of the drug baclofen to reduce severe spasms. The pump can also be filled with high levels of pain medication either alone or in combination with baclofen. The pump slowly bathes the spinal cord in medication. Medication delivery can be adjusted to fit the varying needs of the day. It is implanted in a surgical procedure. Prior to surgery, a test is conducted to establish certainty of the treatment. Battery replacement is done by surgery when needed. The drug in refilled in the device by injection in the healthcare provider’s office.

If you are still having difficulty with control of neuropathic pain or you do not want to take oral medication because of side effects or brain fog, nerve stimulators might help. These are devices that are placed on the skin, outside of the body, or are surgically implanted that create an electrical current to block the pain nerve impulse from traveling through to the brain. The impulse from the nerve stimulator breaks up the internal nerve transmission.

Nerve stimulators can be small devices such as TENS (trans electrical nerve stimulators). These devices utilize electrodes placed on the skin through which a light electrical current is transmitted to the area of pain. Generally, these devices are used for pain in a specific area.

Spinal cord stimulators are used for more general body nerve stimulation. These devices have an electrode implanted near the spinal cord to break up the transmission of the miscommunicated messages. The electrode is inserted using guided imagery or x-ray. An external device can be adjusted to find just the right amount of energy you need for your specific pain needs.

Use of functional electrical stimulation (FES) can deliver greater exercise to the muscle for neuropathic pain reduction. In this therapy, electrodes are applied to your skin which cause your muscles to contract and relax. FES delivers great potential for movement and reduction of risk for many secondary complications of spinal cord injury. There is research that includes pain reduction. However, obtaining this equipment is not always practical and can be difficult as it is not typically approved by payors.

Motor cortex stimulation where electrode(s) are placed on the surface of the brain has been used to treat neuropathic pain. It is a major surgical procedure. The FDA has not yet approved this treatment, but it has been done off label, which means by special exemption. Over time, this could become a routine, although serious treatment. Research is active in this area.

There are a couple of new neuropathic pain treatment techniques that are still on the research drawing board. One is a connection with silent Autonomic Dysreflexia (AD). Typically, AD has been diagnosed by a trigger such as catheter blockage or other noxious stimuli. This results in high blood pressure or other AD symptoms. Then the diagnosis of AD is made. The diagnosis pattern is trigger, symptom, diagnosis. However, there is a new thought that the diagnosis of AD may be silent, meaning no trigger or symptoms. A complete upending. Neuropathic pain could be a result of AD. Treatment of some types of AD might be a treatment for neuropathic pain. More work needs to be completed in this area.

Another possible treatment for neuropathic pain could be magnetic therapy. We all know the heart has a rhythmic pattern. The brain does as well, and this pattern has been mapped. Currently, the electrical flow of the spinal cord is being mapped. Magnetic therapy might be developed into an effective treatment for neuropathic pain. Currently, some brain issues are being effectively treated with transcranial magnetic therapy. This might be a help to those with neuropathic pain in the future.

Neuropathic pain is an issue for many with spinal cord injury. Finding an effective treatment is individual to each person with this condition. What works for one might not work for another person. Trying different strategies is helpful as well as combining therapies. This is not a one size fits all situation. What did not work last year, might work for you now. Neuropathic pain is always changing. Your treatment may need to change along with it. Nurse Linda

Pediatric Consideration: Treating pain in children is a similar process to treating individuals. Children are much more open to some of the non-invasive techniques. They are more susceptible to distraction; however, pain is relentless.

The older child will be able to communicate changes or improvement in pain control. It may be much more difficult to assess the younger child’s pain. There is a simple pain scale that uses facial expression to assess the pain of young children. Don’t forget to look at children’s changes in behavior, eating and sleep patterns as an indicator of pain.

For everyone, noting behaviors and attitudes will be beneficial to treating neuropathic pain. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.