Neuropathic pain is a complex phenomenon, encompassing the sensory experience of severe, unremitting pain with associated allodynia, hyperpathia and/or dysthesia; as well as the emotional experience of hypersensitivity, poor concentration, sleep disturbance, increased arousal and mood lability.
We have already discussed the assessment of neuropathic pain; and pharmacologic treatment of neuropathic pain. In 2010, NICE reviewed the evidence for pharmacologic treatment . Its guidance, like many NICE publications, remains controversial. Please review the guidance and critique the evidence in the light of the following
- Why is the use of pregabalin recommended over gabapentin?
- What were the total number of patients used to derive the NNT for amitryptiline?
- Why has Duloxetine been recommended as a first line therapy for painful diabetic neuropathy?
For another recent review consult Finnerup et al .
This article focuses more on modifying the emotional and cognitive experience of pain by focusing on methods of helping the patients develop better self-management strategies and less on modifying the purely sensory aspect of the pain experience.
Effectively, for a successful management strategy to be arrived at, the patient and the health care professionals must work in a partnership. This starts with an atmosphere of trust and belief. Vital to the success of this interaction is the acceptance of the Biopsychosocial model to contextualize the patient’s condition. Turk  has written about this concept in detail. Read the chapter and use it to familiarise yourself with the model prior to continuing with the material in this article.
The Problem of Being Believed
Because there are no “objective” tests to quantify pain, we have to rely on the patient’s report of pain intensity to guide therapy.
Initially, the patient should feel their autonomy and wishes are being respected. These patients may have suffered with their conditions for many years and have often been in contact with many hospital departments. They may present with
- copious documentation (I have a list here…)
- fixed ideas (“I have been told I have a crumbling spine”)
- frustration (“I just want it sorted!”)
- hopelessness/helplessness (“you won’t be able to help me, no one can”)
Patients may have had little or no explanation of the nature of their problem, little access to information and virtually no support. Often, medication has been trialed, which has been unsuitable or poorly tolerated or ineffective. Even with the best evidence-based criteria, pharmacologic therapy may still fail or be insufficient to control both pain intensity and pain’s interference with activities of daily living and sleep.
Building an atmosphere of trust can be facilitated in the initial stages of patient contact- by the use of
- open questions
- using empathy
- frequent summaries of the patient’s history as it is being recorded.
For an introduction to the patient consultation for nurses, see Baird .
It is worth considering that patients with long-term painful conditions often fulfill many of the DSM-IV criteria for a depressive illness – in fact newer studies  suggest that similar areas of the mesencephalon can be affected in both conditions. The link between experiencing pain and experiencing depressive symptoms should be introduced to the patient, who initially be resistant to this link. Many patients who have soldiered on with their symptoms for years are very resistant of the label “depression”; and feel it is a value judgment by the health care professional on their coping strategies (“I’m not depressed, I have pain!”). They may also feel stigmatized.
However, tactful explanation of the link between chronic pain and depressive symptoms within a context of trust may allow patients to be more accepting of strategies which will help their condition. Severe depressive symptoms should be treated with input from psychiatric colleagues who can advise on optimal pharmacotherapy. In the patients with pre-existing mental disorders, common anti-neuropathic treatments, such as gabapentin, may actually worsen depressive symptoms- although there is good evidence that pregabalin may be useful in patients who fulfill the criteria for anxiety disorder .
From the Acute Pain to the Biopsychosocial Model
Patients should be encouraged to contribute to their own treatment plan, but they should also be guided towards an acceptance of the biopsychosocial model. Although the emphasis is on management of pain at a cognitive, rather than pharmacologic level, there may well be reports of a decrease in absolute pain intensity. This may be due to a number of factors such as
- increased self-efficacy
- decreased fear
- increased movement preventing secondary musculoskeletal pain
- better ‘gating’ of pain resulting from cognitive efforts.
There are several strategies that should be incorporated into a non-pharmacologic approach.
- Education about condition
- Patient preference
- Modification of sensory aspects of pain
- Modification of cognitive/emotional aspects of pain
- Built-in assessment and reassessment
Educational resources for patients can be provided by condition-specific patient groups, such as Persistent Pain Program, Arthritis UK, the Arthritis Reasearch Campaign, Fibromylgia UKand the American RSD Hope group. The Persistent Pain Program UK has publishes a “Pain Toolkit” booklet, which can be supplied or downloaded free-of-charge. This booklet aims to introduce the ideas of non-pharmacological techniques to manage chronic pain.
A Word of Caution
In recommending a support group, the health care professional should regularly check its website to see if it is still operating; that the site is not sponsored by a commercial concern and the information is up-to-date and as evidenced-based as possible. Some websites make wild claims of cures, or endorse dubious treatments. The common sense rule is never to recommend a source of information that you have not first looked at yourself.
Non-pharamacologic therapy focuses on treatment modalities that modify physical or cognitive aspects of the painful condition.
Non-pharmacological therapies can be divided into:
Further divisions can be made:
|Pain Management Programs
|Recovery Model (peer-to-peer)|
Ethics of non-pharmacologic treatment
Review the article by Edwards et al  on the ethics of RCTs for patient benefit. Now review the voluntary ethical code for complementary medical practicioners.
- In the GMC’s “Good Medical Practice”,care providers are obliged to provide effective treatments based on the best available evidence…(and)…take steps to alleviate pain and distress whether or not a cure may be possible
Please review Dr Mick Serpell’s presentation on Justice and Chronic Pain.
Consider how ethics impact on your practice. Is your practice governed more by the needs of the patient or by the needs of your local service? How are the ethics of decisions about service provision analysed?
Part of consideration of the choice of therapy is not only the health care professional’s skill or expertise at delivering a particular therapy, but also the patient’s choice and the acceptability of that therapy for a patient. Ethically, the evidence for treatment should guide decision making, but the patient’s social, cultural and religious context should also be considered.
Although, for example, CBT may be seen as an acceptable (and indeed, highly evidence- based) treatment; it may be culturally impossible for a patient at a certain stage in their journey to accept this.
Part of the ‘art’ of pain management is knowing when a particular therapy will be accepted by a patient when offered. The transtheoretical model in health psychology assesses an individual’s readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance.
The “stages of change” model
Therefore, the acceptability of a particular therapy to a patient, e.g. a psychological therapy may change as the individual moves through the various stages of change.
Modification Of Sensory Aspects Of Neuropathic Pain
In this section, we will focus mainly on the evidence for non-interventional aspects of sensory modification. This section is accompanied by the presentation “Non-Pharmacological Techniques for the Treatment of Neuropathic Pain”.
The IASP definition of pain describes it as sensory and emotional experience. Modification of the sensory aspects of pain without recourse to drugs involves the following strategies:
- Simple measures– heat, ice, massage, manipulative therapies (e.g. chiropractic, osteopathy), physiotherapy
- Treating the primary cause– e.g. improve diabetic control; supplement thiamine; reduce/stop alcohol consumption. Treating the primary cause includes interventional techniques such as surgery for disc prolapses or spinal stenosis; or nerve translocation surgery (e.g. carpal tunnel release)
- Stimulating inhibitory mechanisms in the periphery or in the spinal cord: e.g. acupuncture /TENS; electrical peripheral nerve or dorsal column or central (deep-brain) stimulation
- Inhibition or prevention of ascending nerve transmission in the peripheral nervous system, in the dorsal root ganglion or spinal cord: e.g. nerve blocks, neurolysis or rhyzolysis
- Alter pain processing at the cortical level, e.g. cognitive therapies, biofeedback, hypnosis, meditation. It is currently unclear the exact way in shich these therapies alter sensation, but is assumed to involved both descending inhibition and alteration of sensitivity to ascending stimulus.
While heat and ice are simple measures, they may be the first choice for patients. Advantages include ease of access and self-administration – however, efficacy of these measures are generally poor. However, when utilized in the context of a comprehensive movement and desensitization strategy, they can be very effective and drug-sparing.
Chiropractic and osteopathy are simple, passive treatments involving the manipulation of joints, bones and soft tissues for the relief of pain. Their efficacy is hard to predict in individual patients; and varies from patient to patient. NICE recommends initial trials of these therapies to identify responders for uncomplicated mechanical low back pain (but does not currently endorse manipulative therapies for neuropathic pain). Provision within the NHS varies from region to region. The full NHS evidence guide, which includes practice guidance from Canada, Australia and New Zealand can be found here.
A quick search of the ClinicalTrials.gov website revealed over 200 registered trials for the use of physiotherapy for various painful conditions including vulvodynia, radiculopathy, fibromyalgia, post-stroke and complex regional pain syndrome. However, few if any of these trials are linked to publications. Does this represent a failure to publish; poorly-designed trials; or lack of efficacy? Certainly, in the treatment of complex regional pain syndrome and post-spinal surgery pain, extended-scope physiotherapists are seen as a vital part of the multi-disciplinary team. So where is the evidence that these techniques are helpful?
A glance at the Cochrane Library shows over 70 reviews which look at the efficacy of physiotherapy in various painful conditions- mostly with positive outcomes. However, many of the reviews highlight the paucity of RCTs; the heterogeneity of trials on the same conditions; or low numbers of participants. With the data from the register of trials and poor publication record, one begins to see the difficulties in obtaining evidence-based guidelines.
However as Carl Sagan said “absence of evidence is not evidence of absence”. The long history of physiotherapy in the treatment of painful conditions, combined with the professions’ insistence on uniformly high standards of education and competence have meant its long acceptance by the NHS in the treatment of chronic, painful conditions.
However, amongst physiotherapists, there are still controversies surrounding certain types of therapies, such as the historical use of traction for lumbar disc prolapse. Although this was common therapy for years, it was only after its evaluation in trials and subsequent analysis showing poor long-term success that its use declined. Currently, ultrasound therapy is under investigation for its efficacy.
Physiotherapists are an essential part of the multidisciplinary team, and invaluable aid to patients with neuropathic pain. They can challenge beliefs about pain and damage, pain and movement and promote normal movement and discourage pain behaviours such as fear-avoidance of movement. They can encourage behavioural strategies such as pacing; and reinforce progress by helping patients set achievable goals.
Acupuncture is the practice of treating illness by the placement of needles into specific points along “meridian” lines. It is an essential part of the treatment plan in traditional Chinese medicine. Traditional Chinese acupuncture is a highly-skilled practice delivered in the context of a paradigm that includes separate skills of history-taking, examination, investigation and treatment planning. For more information about traditional acupuncture, see Wikipedia as a starting point.
In the West, interest in acupuncture as a treatment modality for painful conditions in the started in the 1970s; after US President Richard Nixon’s trip to China. The interest in acupuncture continued throughout the 1970s and 1980s, but it was not until the late 1980s that acupuncture began to be investigated with RCTs designed to look at its efficacy.
A search on PubMed reveals 1895 hits for the search terms “acupuncture” and “pain”, with over 300 reviews and trials. Of those, approximately 28 were identified as meta analysis or evidence-based reviews, the rest being not related to painful conditions; or were case series.
Most meta-analyses or reviews found moderate benefit for a variety of painful conditions; including migrane, cervical and lumbar back pain or musculoskeletal conditions; and no or little effect on rheumatoid arthritis.
Acupuncture is recommended by NICE for the treatment of uncomplicated low back pain in primary care in the first 12 months. There is little evidence to suggest that acupuncture can be effective in the treatment of neuropathic pain; but it can often help secondary musculoskeletal pain resulting from guarding and abnormal posture/gait. Further information and a variety of evidence and information for patients can be found on the British Medical Acupuncture Society’s website here.
Transcutaneous Electrical Nerve Stimulation (TENS)
Transcutaneous electrical nerve stimulation (TENS) is a non-invasive treatment modality developed Dr Norman Shealy in the 1960s. The principle by which TENS is thought to work is that stimulation of the Abnerve fibres causes interference with and temporary interruption to pain transmission in the c-fibres and Adfibres at the dorsal horn and spinal levels.
The TENS unit is a small box containing a battery-operated pulse-generator, the frequency and intensity of which can be controlled by the user. The pulses are then transmitted to the user’s skin via adhesive electrode pads.
Advantages of TENS include its low cost, ease of use, freedom from side effects and portability. Disadvantages of TENS include lack of efficacy in many patients, problems with positioning for disabled patients, expense of consumables (pads and batteries) and short duration of pain relief following discontinuation of TENS stimulation.
The Cochrane Database reviews have repeatedly raised concerns about both the trial design and methodology of TENS trials in chronic pain and cancer pain. Dr Mark Johnson is one of the UK’s most vocal champions of TENS as a treatment modality, and has published a wealth of information on his home page at the Leeds University site. In contrast, the Bandolier website is quite negative regarding TENS; although its (anonymous) authors do agree that there may be some benefit in a trial of TENS for patients to see if they respond.
Many pain clinics and physiotherapists run a TENS loan service. Many patients do benefit from the use of TENS, especially if they have problems tolerating the side effects of medications. For needle-phobic patients, TENS may be preferable to acupuncture or nerve blocks. The best recommendation for a trial of TENS starts with a short teaching session, which can be delivered in a group setting. The aims of teaching are to:
- Explain its advantages and disadvantages;
- Explain what can and cannot be expected from therapy
- to caution patients against using the machines for longer than the recommended times (twice daily for 45 min to 1 hour)
TENS is often best-utilized either just prior to just after activity rather than at rest. Patients should be cautioned about not driving with the machine on, as this may interfere with their ability to accurately use foot pedals. Patients with pacemakers should take advice from their local pacemaker service; and should not use leads near the pacemaker site. Pregnant women should not use TENS in the first trimester- and thereafter only under supervision of the local obstetric and/or Pain service.
Nerve Blocks and Neurolysis
If a single nerve or nerve root can be found which is responsible for the patient’s pain, a nerve block may be considered. The purpose of nerve blocks is to temporarily (or permanently) interrupt nerve transmission and relieve pain- thereby allowing the patient to move more normally. Please review the presentation on Interventional Pain Relief Techniques for a full discussion of these techniques.
There is a great deal of controversy surrounding the use of nerve blocks due to a paucity of homogeneous trials- there are large variations within the published trials in patient selection; disease or condition; injection technique, and outcome measures. While the evidence for (and clinical benefit) of e.g. coeliac plexus blocks in the treatment of pain arising from pancreatic cancer is excellent; evidence for local anaesthetic and steroid injection to the zypopheseal (facet) joints of the spine is more controversial. Please consult a recent paper by Manchikanti et al . A very full and complete guide to various nerve blocks and their indications in chronic pain treatment can be found here. Certainly, nerve blocks may temporarily:
- interrupt the cycle of pain and spasm
- allow patients more normal movement
- decrease the amount of analgesia used
- improve functionality either in the short or medium-long term
The decision to offer nerve block treatment is one that requires exceptional skill from the operator and comes with a provision that the patient will understand the purpose of the nerve block: either as a sole agent to relieve pain or, (more commonly) as an adjunct to rehabilitation. The patient should be well-informed and realistic about what to expect from a nerve block. Repeated nerve blocks in the absence of engagement in rehabilitative strategies are counter-productive for the patient- they foster a passive attitude towards rehabilitation and shift responsibility for the management of the condition to the health care professional rather than encourage self-management. Access to nerve blocks is often a lengthy and difficult process due to the high demand for these procedures- and patients should be told from the outset that the blocks are part of a comprehensive biopsychosocial management process.
Diagnostic nerve blocks are a therapeutic trial – designed to both identify the structure causing the pain; but also to relieve pain temporarily. More permanent neurolytic procedures are employed (after a successful trial of diagnostic block) to give longer lasting pain relief. However, no technique appears to be permanent; and pain may recur, even after neurolysis or cordotomy. Repeated nerve blocks may be performed for palliation in cancer pain or in inoperable conditions such as severe spinal stenosis in patients unsuitable for surgery; but they are not a cure for the disease process, nor should they be portrayed as such.
Modification of cognitive/emotional aspects of pain
These therapies, often called the ‘psychological therapies’ focus on altering patients’ cognitive, emotional and behavioural responses to pain. Included in this category are other therapies, such as eye movement desensitization therapy (EMDR); hypnosis and meditation.
Evidence for the effectiveness of psychological therapies was first systematically analysed by Morley, Eccelston and Williams in 1999 . The same authors then re-analysed data specifically on Cognitive Behavioral Therapy (CBT) and behavioral therapies (BT) for NHS Evidence in 2009 . The authors concluded that careful selection of patients is necessary but evidence suggests that there are sustained (>6 months) improvements in pain, mood and disability. There is currently no evidence as to which therapy should be used in which groups, however. For an excellent review of both psychological therapy and self-hypnosis consult Molton et al .
Acceptance and Commitment Therapy (ACT) is a refinement of CBT, which focuses on mindfulness and acceptance of the current condition. You will be familiar with these strategies from your psychological therapies module. Please review Dr Lance McCraken’s PowerPoint for further information.
In addition, psychological therapies may prove useful where pharmacology is not recommended, such as in children and adolescents .
Hypnosis has been in use for pain management since its inception. As far back as 1959, analysis of its usefulness and speculation as to its mode of action was underway. It has been variously thought to act via the endogenous endorphin and/or dopaminergic system. Hypnosis-induced analgesia is not, however reversed with naloxone.
More recent work has focused on determining whether hypnosis shares a similar physiological mechanism to that of placebo responders .
Assessment of the success or failure of different strategies for the treatment of neuropathic pain are as important as reviewing the effectiveness of drug therapy.
Assessment may be done in person, over the telephone or by posting a questionnaire. However, it is essential to gain feedback from the patient; as even a patient with chronic pain may develop new disease processes which may present with an exacerbation of existing symptoms; or with new symptoms. Ongoing assessment may help control costs, as ineffective therapies or those that the patient does not like (or comply with) can be discontinued.
A wide variety of scales exist for the measurement of neuropathic pain – LANSS is a common and easy-to-use scale ; there is also a NPS – Neuropathic Pain Score . Both of these scales take into consideration the other phenominologic aspects of neuropathic pain- such as sleep disturbance, low mood/anxiety and sensory abnormalities such as allodynia. These aspects are vital to the assessment process- as previously mentioned, the sensory aspects of neuropathic pain rarely change very much. However, an improvement in sleep, mood or function; or a change in sensitivity may be equally beneficial for the patient.
After assessment comes action. The practitioner must use the information from the assessment to change or guide therapy. In some cases, the patient may experience only trivial changes in assessment scales, but this may be a significant outcome for them. An action plan should follow each assessment, taking into consideration patient preferences and previously successful and unsuccessful strategies. While patients should be included in treatment planning, using a previously unsuccessful strategy (such as an escalation in opioid treatment) is neither effective nor desirable, despite a patient’s preference for that particular course of action.
Assessment should guide practice as a whole. Feedback is vital to inform patient treatment and also to benchmark the performance of your practice or service against others. Ongoing audits of numbers treated, effectiveness of treatment, costs of treatment and patient satisfaction should form a core of any service, whether in general practice, the community or secondary care.
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