Neuropathic pain: what is it and how to overcome it

• Sleep disturbance
• Depression
• Numbness in the affected area
• Pain sensitivity disorder
• Anxiety
• Pain in the absence of pain
• Burning sensation in the affected area
• Tingling in the affected area

Neuropathic pain is a pathological condition manifested by a restructuring of the somatosensory processing of body signals, which leads to the manifestation of a pronounced pain syndrome. This symptom progresses due to damage or dysfunction of peripheral nerves - either one or several at once. This can occur as a result of a pinched nerve fiber or a disruption in its nutrition.

• Etiology
• Varieties
• Symptoms
• Diagnostics
• Treatment
• Prevention

Due to damage, the affected fiber ceases to function normally and sends incorrect signals to the brain. For example, a nerve can transmit a signal to the brain that a person has touched a hot object, but at this time nothing of the kind happens. But the brain sends a signal back and in a completely healthy place the patient begins to feel a strong burning sensation, as if from a burn. Most often, this pathological condition manifests itself in various pathologies of the central nervous system, endocrine system, trauma to certain parts of the body, etc.

What is neuropathic pain and how to deal with it?

Neuropathic (neuropathic) pain is usually called pain caused by pathological excitation of neurons, and not by the effect on pain receptors. Its simplest difference, accessible to a person without medical education, is that there are no visible factors that could cause it. Or its nature and intensity do not correspond to the type of damage.

According to medical statistics, at least 6-7% of the population suffers from it, and it causes approximately every eighth to tenth visit to a neurologist.

Neuropathic pain can be the result of a previous inflammatory process or injury, including after surgery. But sometimes it develops when the nervous system is damaged as a result of a systemic disease, for a number of other reasons.

This also includes so-called phantom pain - pain in a remote organ or part of the body. For example, a patient may experience pain for no apparent reason after an amputation or even extraction of a tooth during a normal healing process.

Newspaper "News of Medicine and Pharmacy" Neurology (339) 2010 (thematic issue)

Top-top is my horse. I see myself in the picture - In the expanse of summer meadows. Basho

The most important reason for patients seeking medical care is pain. It accompanies most diseases and pathological conditions.

Unfortunately, today there is still a stereotypical idea of ​​pain as a symptom of some disease. This attitude is only true for acute pain, which occurs during injury, inflammation or ischemia and represents a signal of damage to body tissues. However, in many patients, the duration of pain exceeds its signaling function and pain turns from a signaling factor into a damaging one, causing long-term suffering.

Over the past 30–40 years, there has been a steady increase in chronic pain syndromes in the overall morbidity structure. The spread of chronic pain in society has become epidemic and, according to various authors, ranges from 15 to 70%. The high prevalence of pain syndromes results in significant material, social and moral losses, negatively affecting a person’s quality of life.

To adequately combat pain, multidisciplinary pain clinics and centers occupy a significant place in the healthcare structure of many countries, whose tasks include providing specialized pain care to patients with pain syndromes and training specialists in pain therapy. For example, there are currently about 4,000 pain clinics in the United States. So what is pain? An adaptive reaction of the body, an alarm signal or an independent disease? On the one hand, pain is an adaptive reaction, the most important protective mechanism that ensures survival, learning and adaptation of living organisms to changing environmental conditions. However, intense acute or chronic pain itself becomes a powerful pathogenic factor, leading to a significant deterioration in the patient’s quality of life.

The International Association for the Study of Pain gives it the following definition (Merskey, Bogduk, 1994): “Pain is an unpleasant sensation and emotional experience associated with existing or potential tissue damage, or a condition described by the patient in terms of such damage and determined by sensory information, affective reactions and cognitive activity."

Types of pain

There are several classifications that take into account types of pain.

Based on time, we distinguish between transient, acute and chronic pain.

Transient pain occurs as a result of activation of nociceptive receptors in the skin or other tissues in the absence of significant damage and exists to protect a person from the threat of physical damage from environmental factors.

Acute pain is a necessary adaptive signal that not only informs about tissue damage, but also causes reflex and behavioral reactions that help reduce the damaging effects to a minimum. Thus, acute pain in a joint warns of the development of inflammation and encourages you to limit or change the trajectory of movement so as not to injure the damaged joint. Acute back pain warns of damage to the musculoskeletal system, encourages you to reduce physical activity and take a position that relieves pain. Thus, acute pain and the resulting behavioral changes are essential for speedy recovery. The duration of acute pain is limited by the recovery time of damaged tissue. Thus, transient and acute pain are the most important protective mechanism that ensures survival, learning and adaptation of living organisms to changing environmental conditions.

Chronic pain is severe, prolonged, debilitating, causing suffering to the patient (Ataman A.V., 2000).

Chronic pain, as defined by the International Association for the Study of Pain, is “…pain that continues beyond the normal healing period.” The most acceptable period for assessing pain as chronic is its duration of more than 3 months (Merskey HM, Bogduk N., 1994).

Chronic pain syndrome, as a rule, is characterized by the absence of a direct connection with organic pathology, or this connection is of an unclear, uncertain nature. Pain, once arising as a result of any damage, leads to serious disturbances in the system of regulation of pain sensitivity, causes psychological disorders, and forms a special form of pain behavior that will persist even when the initial triggering cause of pain is eliminated.

Chronic pain is pathological pain that has acquired a “superorgan” character, i.e. independent chronic disease. It does not perform a protective, educational or adaptive function, but only brings suffering and reduces the quality of life. An example of such pain in neurological practice would be back pain that does not go away after restoration of normal spinal biomechanics and a normal x-ray picture.

Chronic pain, regardless of the cause that initially caused it, is a consequence of the development in the peripheral and central nervous system in response to prolonged painful stimulation of a number of successive changes, gradually acquiring the character of a typical pathological process. These changes consist of the following main stages (Kukushkin M.L., Reshetnyak V.K., 1997; Kryzhanovsky G.N., 2002; Borsook D., 1997):

1. Increased flow of pain impulses from the periphery due to increased release of tissue and plasma algogens (histamine, serotonin, prostacyclins, leukotrienes, cytokines, bradykinin, etc.) and the development of peripheral sensitization, manifested by primary hyperalgesia and allodynia.

2. The emergence of antidromic stimulation and the development of neurogenic inflammation at the site of the lesion with the release of neurogenic algogens and neurotrophic factors (substance P, calcitonin-gene-related peptide, nerve growth factor, etc.), promoting increased peripheral sensitization and the flow of pain impulses into the central nervous system .

3. Activation of NMDA receptors of neurons in the dorsal horns of the spinal cord, increased release of specific neurotransmitters and neuromodulators in synapses (glutamate, calcium ions, nitric oxide, substance P, neurokinin-1, c-fos oncogenic protein, etc.), development of central sensitization with subsequent depletion and death of neurons, development of zones of secondary hyperalgesia.

4. Weakening and disintegration of the natural antinociceptive system, development of opiate tolerance.

5. Formation in the dorsal horns of the spinal cord and other parts of the central nervous system of aggregates of hyperactive neurons with weakened inhibitory control - HPUV.

6. Formation of a pathological algic system (PAS), which includes various levels of the central nervous system and determines the course and nature of all components of pathological pain: pain perception, suffering and pain behavior.

The clinical structure of chronic pain syndrome is heterogeneous and is often a combination of musculoskeletal pain (nociceptive), neuropathic pain and pain of a psychological nature. Pain syndrome in this case is transformed from a symptom reflecting damage to tissues or structures of the nervous system into an independent form of the disease, the pathogenesis of which includes not only mechanisms for increasing the excitability of nociceptive neurons, but also the formation of special pathological integrations in the structures that regulate pain sensitivity and the development of psychological disorders , distorting the final perception of pain.

Thus, chronic pain is determined not only by the time factor (duration of pain over 3 months). This pain is detached from the root cause and becomes an independent disease associated with disruption of the systems that control pain sensitivity.

The process of developing chronic pain begins with the onset of its occurrence. The longer and more intense the pain in any part of the body, the more the part of the nervous system that controls this area is disinhibited. Each new attack of pain makes the road easier for the next pain paroxysm. If at the beginning of the disease back pain occurs, for example, when lifting weights of more than 50 kg, then as the disease progresses, the threshold decreases to 10, then to 3 kg, and soon exacerbations of pain are provoked simply by awkward movement or emotional stress.

Among chronic pain syndromes, the most common are back pain, headaches (chronic tension headache), musculoskeletal pain (including fibromyalgia), pain in cancer patients, and neuropathic pain.

For clinicians, the most acceptable is the pathophysiological (pathogenetic) classification, which also makes it possible to take a differentiated approach to pain treatment. The need for a new perspective on pain has arisen because pain syndromes have been shown to be differentially responsive to different forms of drug therapy. Doctors are faced with a situation in which identification and elimination of damage is not accompanied by the disappearance of pain. Thanks to the presence of this therapeutic problem, a division of pain syndromes into two groups arose: nociceptive and neuropathic.

It turned out that the pain that is treated with non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics is pain caused by irritation of pain receptors - nociceptors, which are located on the skin, muscles, ligaments and internal organs. These are types of pain in which there is tissue damage: burn, injury, inflammation, sprain.

But there is a second category of symptoms that cannot be treated with these drugs. Pain syndromes of this group, in which pain is associated not with irritation of receptors, but with damage to the nervous system, were called neuropathic.

Thus, from the point of view of pathogenesis, nociceptive and neuropathic pain are distinguished. Nociceptive pain occurs when a damaging factor (mechanical, thermal, chemical) affects pain receptors, including in the case of a local inflammatory process. The intensity of pain is determined by the ratio of the activity of the nociceptive (pain) and antinociceptive (anti-pain) systems. In this case, the pathways and parts of the central nervous system are not involved in the pathological process, and as the irritation of the receptors decreases, the pain subsides. Nociceptive pain is often acute. Neuropathic pain occurs with organic damage to the peripheral (nerves, roots, plexuses) or central (posterior horns and columns of the spinal cord, trunk, thalamus, cerebral hemispheres) nervous system, while pain sensations can occur without connection with irritation of the receptor apparatus .

Pathophysiology of nociceptive pain: increased excitability of nociceptors - sensitization. The pathophysiological basis of neuropathic pain is a violation of the generation of potentials in the damaged nerve and inhibitory control of the excitability of nociceptive neurons in the central structures of the brain. One of the main mechanisms of neuropathic pain is an increase in the excitability of nerve fiber membranes, which is associated with an increase in the number of active sodium channels.

Features of neuropathic pain

Neuropathic pain has its own characteristic differences. First of all, this is a complex of specific sensory disorders that can be divided into two groups. On the one hand, these are positive symptoms (spontaneous pain, allodynia, hyperalgesia, dysesthesia, paresthesia), on the other, negative symptoms (hypoesthesia, hypalgesia). Neuropathic pain is characterized by a combination of sensory positive and negative symptoms, which can change in the same patient during the course of the disease.

The phenomenon of allodynia is characteristic of the neuropathic type of pain. Allodynia is the occurrence of pain in response to a stimulus that does not normally cause pain. In such cases, patients experience severe pain at the slightest touch, sometimes even when the wind blows. There are thermal (the effect of a temperature stimulus) and mechanical (the effect of a mechanical stimulus) allodynia. Mechanical allodynia is divided into static, which occurs when pressure is applied to a fixed point on the skin, and dynamic, which occurs with moving stimuli, for example, when the skin is slightly irritated with a brush or finger.

Hyperalgesia is characteristic - the appearance of a pronounced pain sensation when a slight nociceptive irritation is applied (minor effect on pain receptors). The application of repeated nociceptive stimuli, especially of high intensity, can cause a sharp, explosive pain sensation, usually poorly localized, the pain can have a burning tint, and persist for a long time after the cessation of irritation (hyperpathy). Allodynia and hyperalgesia can be combined with decreased sensitivity in the affected area - pain anesthesia. Along with changes in sensitivity, autonomic disorders in the corresponding area are often detected - changes in skin color (hyperemia or cyanosis), impaired tissue trophism, sweating, swelling. As a rule, such patients have disturbed sleep and have depressive and anxiety disorders.

Knowledge of the pathophysiological mechanisms of pain and their relationship with emerging clinical symptoms is important for differentiated treatment. Thus, shooting paroxysmal pain (for example, with trigeminal neuralgia) is caused by ectopic discharges generated by damaged nerve fibers. The occurrence of ectopic discharges is associated with an increased density of channels for Na+ ions in the damaged nerve, and, therefore, the use of sodium channel blockers (carbamazepine), which stabilize excitable membranes, will be justified for these symptoms.

The cause of constant burning pain is considered to be a violation of central inhibition of nociceptive neurons. This inhibition is mediated by both spinal and supraspinal mechanisms. In the spinal cord, the excitability of nociceptive neurons is controlled by GABA and glycine. Descending supraspinal inhibition is realized by serotonin-, norepinephrine-, and opioidergic neurotransmitter systems. In this regard, the administration of tricyclic antidepressants, which block the reuptake of serotonin and norepinephrine, will effectively suppress persistent burning pain. A similar result is observed with gabapentin, which increases the synthesis and concentration of GABA in the spinal cord.

It is believed that symptoms such as paresthesia and dysesthesia are largely due to ectopic discharges in damaged nerve fibers. And, therefore, the appointment of mexiletine, a sodium channel blocker, will be completely justified.

Mechanical allodynia is a common symptom in patients with neuropathic pain. The main mechanism for the development of allodynia is a violation of GABA- and glycinergic inhibition of nociceptive neurons in the dorsal horns of the spinal cord with a simultaneous increase in NMDA-mediated excitation. Therefore, the use of drugs that enhance GABAergic inhibition (gabapentin) and suppress the activity of NMDA receptors (ketamine) demonstrates high effectiveness in eliminating allodynia.

Secondary hyperalgesia in patients with neuropathic pain (reduced pain thresholds outside the area of ​​injury) occurs as a result of central sensitization of nociceptive neurons due to increased nociceptive afferent flow, and, therefore, inhibition of ectopic discharges by local administration of local anesthetics is quite reasonable.

We often observe a dissociation between the severity of pain and the degree of damage to the nervous system.

Peripheral neuropathic pain occurs in polyneuropathies (diabetic, alcoholic, chronic inflammatory demyelinating, nutritional-related, idiopathic sensory), tunnel neuropathies, nerve injury (phantom pain), postherpetic neuralgia, trigeminal neuralgia, root compression (radiculopathies and radiculoischemia), complex regional pain syndrome (accompanied by local pain with swelling, trophic disorders and osteoporosis). Central neuropathic pain develops when the spinal cord, brain stem, thalamus optic and cerebral cortex are damaged (compression, vascular, HIV-related myelopathy, tumor, spinal cord injury, syringomyelia, funicular myelosis, multiple sclerosis, post-stroke pain, pain in Parkinson's disease.

Nociceptive pain is often acute in its development, while neuropathic pain is predominantly chronic. In certain cases, there is a combination of nociceptive and neuropathic components of pain (compression radiculopathies, cancer pain, tunnel syndromes).

Examination of a patient with chronic pain syndrome

Pain is a subjective phenomenon, so today there are no unified objective methods for diagnosing it. However, to assess multifactorial pain syndrome, a minimum number of standard diagnostic tests are used to assess pain and the effectiveness of its therapeutic correction in clinical practice. Based on the modern definition of pain, its detailed assessment should be based on the patient’s subjective sensations, his affective reactions in response to a painful stimulus, physiological indicators and “pain behavior.” A thorough interview, examination of the patient and an objective neurological and somatic examination play an important role. When examining patients with chronic pain syndrome, special attention is paid to clinical signs such as the individual’s excessive attention to his physical condition, depressed mood or anxiety. Specific characteristics of pain that indicate poor psychological tolerance to nociceptive stimuli are the following: pain prevents a person from performing his daily duties, but nevertheless does not prevent him from going to bed peacefully; the patient vividly and vividly describes the pain experienced and demonstrates with all his behavior that he is sick; experiences pain constantly, but the pain does not change; physical activity increases pain, and increased attention and care from others softens it.

Thus, to assess the severity of chronic pain syndrome, objectification of pain and psycho-emotional state is necessary.

To unify the patient’s description of pain and objectify the patient’s experiences, questionnaires were created consisting of sets of standard descriptors common to all patients. The most commonly used is the McGill Pain Questionnaire (MPQ), which contains verbal characteristics of the sensory, affective and motor-motivational components of pain, ranked according to five intensity categories. The advantage of the questionnaire is that it allows you to differentiate the organic nature of pain and identify the psychological state of the patient. Numerous studies of pain conducted using a questionnaire have shown that all indicators in the affective class were higher in emotionally labile individuals with a tendency to anxious and depressive reactions, in women - higher than in men, in patients with chronic pain compared to acute pain. Due to the labor-intensive nature of the research, the McGill Questionnaire in our country is used mainly in scientific research.

Since pain is closely related to emotional status, quality of life questionnaires and psychological methods that allow assessing the severity of anxiety and depression play a role in its characterization and selection of optimal therapy.

In clinical practice, scales can be more often used to assess the intensity and severity of pain, as well as determine the effectiveness of the treatment:

1. Simple descriptive pain intensity scale (five-digit):

- no pain - 0;

- mild pain (slightly hurts) - 1;

- moderate (painful) - 2;

- severe (very painful) - 3;

- unbearable (unbearable) - 4.

2. Verbal quantitative scale (10-point scale for assessing pain intensity) - from no pain to unbearable. The patient names the number corresponding to the pain.

3. Visual analogue pain scale - when used, the patient marks on a line how severe his pain is from 0 to 10. The scale can be used from 6 years of age.

To determine pain as neuropathic, there are special questionnaires - Questionnaire DN4, Pain Scale LANSS.

DN4 Questionnaire (Didier Bouhassiraa, Nadine Attala et al., Pain 114 (2005) 29–36)

Please complete this questionnaire by checking one answer for each item in the 4 questions below.

Interview with the patient

Question 1: Does the pain experienced by the patient meet one or more of the following definitions?

Question 2: Is the pain accompanied by one or more of the following symptoms in the area where it is localized?

Patient examination

Question 3: Is the pain localized to the same area where examination reveals one or both of the following symptoms?

Question 4. Is it possible to cause or intensify pain in the area where it is localized?

Total points (number of “Yes” answers): __________

If the sum is 4 points or more, this indicates that the patient’s pain is neuropathic or there is a neuropathic component of pain (with mixed nociceptive-neuropathic pain syndromes with a probability of 86%).

LANSS pain scale (Leeds Assessment of Neuropathic Symptoms and Signs, Bennett M., 2001)

Neuropathic Symptoms and Signs Rating Scale

A. Pain questionnaire

Think about how your pain has felt over the past week.

Please tell me which definition best describes your pain.

Question 1. Do you feel your pain as an unusual, unpleasant sensation in your skin? Can these sensations be described by adjectives such as stabbing, pinching, piercing or penetrating?

Question 2: Does the skin color in the area where the pain is located look different than normal? Would you say it is blotchy or looks red or pink?

Question 3: Does sensitivity to touch change in the area where the pain is located? Does it become unpleasant, for example, if you lightly rub your hand over the skin, or painful when you put on clothes?

Question 4: Does your pain come on suddenly, suddenly, for no apparent reason, even when you are at rest? Could it be described as an electric shock, a jump, or an explosion?

Question 5: When you feel pain, can there be any unusual temperature sensations in that area? Can they be described as burning or burning?

B. Sensory testing

Pain sensitivity can be tested by comparing a painful area with a contralateral or adjacent non-painful area for the presence of allodynia or changes in tingling pain thresholds (PPT).

1. Allodynia

The response to a light tactile touch (cotton, wool) in the non-painful and painful areas is checked. If normal sensitivity is recorded in a healthy area, and pain or discomfort is detected in the painful area, then allodynia is present.

2. Changed tingling pain threshold (PPT)

The pain threshold for tingling is determined by comparing responses to a needle prick applied gently to the surface of the skin of the non-painful and then the painful zone.

If the tingling sensation is felt acutely on the non-painful side, but is perceived differently on the pain side, for example, absent, or dull (increased PPT), or too much pain (decreased PPT), then the pain threshold for tingling is considered altered.

Summation

To obtain the final sum, the values ​​of the parameters of sensory descriptors and sensitivity testing are added. Total amount (maximum 24)……..

If the sum is <12, then neuropathic mechanisms of pain formation are unlikely.

If the sum is >12, then neuropathic mechanisms of pain formation are likely.

Assessment of the patient’s psychological state is a necessary component of the diagnostic complex when examining a patient with chronic pain syndrome. Numerous clinical and epidemiological studies have established that there is a close connection between chronic pain and psychoemotional disorders. The most common psycho-emotional manifestations of chronic pain are clinically pronounced deviations: anxiety, depression, apathy, fatigue and asthenia, increased excitability, insomnia, irritability. Data on the prevalence of psychoemotional disorders among patients with chronic pain range from 30 to 87%. Some researchers consider psychoemotional disorders to be the leading factor in decreased performance in patients with chronic pain and the most significant motivation when seeking medical help. To assess the psychopathological correlates of pain, special psychological tests and questionnaires are used:

— subjective tests (questionnaires, questionnaires or self-assessment scales that are filled out by the patient);

— Spielberger self-assessment scale of personal and reactive anxiety;

— Hospital Anxiety and Depression Rating Scale;

- Beck Depression Rating Scale.

Instrumental methods. The following methods are also used in scientific research. Algometry is a method that involves quantitatively measuring the subjective report of pain when presented with painful stimuli of increasing intensity. Most commonly used in the study of myofascial pain. Electrometry allows for a quantitative assessment of the pain sensitivity threshold. It consists of presenting single electrical stimuli, with the help of which pain sensitivity thresholds are established, determined by the amplitude of the minimal electrical stimulus.

Of course, such a multifaceted study of various pain characteristics can only be afforded by specialized clinics dealing with pain problems.

Treatment strategy for neuropathic pain

Due to the variety of pain mechanisms, treatment for each patient must be individualized taking into account the disease that caused the pain, as well as the clinical characteristics of the pain syndrome itself. Analysis of the pain syndrome from the point of view of its pathophysiological mechanisms (nociceptive pain, neuropathic, mixed) is very important, primarily from the point of view of treatment. If the doctor assesses the pain as nociceptive, then the best means of treating it are simple analgesics and NSAIDs. If the pain is neuropathic or there is a neuropathic component, then the drugs of choice are anticonvulsants (pregabalin, gabapentin), antidepressants, opioid analgesics and lidocaine. In the case of mixed pain syndromes, combination therapy is possible with a choice of drugs depending on the presence of nociceptive and neuropathic components.

In the treatment of neuropathic pain, an integrated approach seems to be most effective. Today there is not enough evidence on the benefits of using conservative non-drug treatment methods (for example, reflexology - acupuncture, laser puncture, physiotherapy, exercise, transcutaneous electrical neurostimulation). However, clinical experience shows their effectiveness in complex therapy, and therefore their use can be recommended. In addition, patients with neuropathic pain require constant psychological support. Rational psychotherapy in this case can play a key role.

The most recognized treatment for neuropathic pain today is pharmacotherapy.

According to the recommendations of the European Federation of Neurological Societies (EFNS) for the treatment of certain conditions accompanied by neuropathic pain, the most recognized treatment of neuropathic pain today is pharmacotherapy.

European recommendations for the treatment of postherpetic neuralgia, trigeminal neuralgia, painful polyneuropathies and central neuropathic pain:

1. Postherpetic neuralgia - first-line drugs: pregabalin, gabapentin, lidocaine topically; second and third line drugs: capsaicin, opioids, tramadol, valproate.

2. Trigeminal neuralgia - first-line drugs: carbamazepine, oscarbazepine; Second-line methods: surgical treatment.

3. Painful polyneuropathies - first-line drugs: pregabalin, gabapentin, tricyclic antidepressants; second and third line drugs: lamotrigine, opioids, tramadol, SSRIs.

4. Central neuropathic pain - first-line drugs: pregabalin, gabapentin, tricyclic antidepressants; second and third line drugs: cannabinoids, lamotrigine, opioids.

For postherpetic neuralgia, local treatment with lidocaine may first be prescribed. It is believed that the action of lidocaine is based on blocking the movement of sodium ions across the cell membrane of neurons. This stabilizes the cell membrane and prevents the propagation of action potentials and consequently reduces pain. It should be borne in mind that the reduction of pain with local use of painkillers does not extend beyond the area and duration of contact with the affected area of ​​the body. This may be convenient for patients with a small area of ​​pain. Lidocaine 5% in patch or sheet form is indicated for the relief of pain associated with postherpetic neuralgia (PHN). Adverse reactions in the form of burning and erythema can be observed at the site of application with prolonged use.

For neuropathic pain of other origin, as well as in case of failure of treatment with lidocaine, it is recommended to begin oral monotherapy with pregabalin or gabapentin, a tricyclic antidepressant or a mixed serotonin-norepinephrine reuptake inhibitor. Of the listed drugs, pregabalin and gabapentin have the best tolerability. These drugs are characterized by an almost complete absence of drug interactions and a low incidence of adverse events. Both drugs have been shown to be effective in treating a variety of neuropathic pain conditions. If the first prescribed drug turned out to be ineffective or poorly tolerated by the patient, you should switch to alternative monotherapy with a first-line drug. If all first-line drugs are ineffective or poorly tolerated, it is recommended to start monotherapy with tramadol or its combination with paracetamol or an opioid analgesic. Unfortunately, this is not always possible, since the prescription of opioid drugs is limited by special requirements for prescribing these drugs.

Treatment of neuropathic pain is a long process that requires regular monitoring of the patient’s health and compliance with medical prescriptions. At the beginning of therapy, special attention should be paid to the correct titration of the dose of drugs and monitor the possibility of drug interactions. Considering the long-term nature of therapy, the development of long-term adverse events (such as hepato- and gastrotoxicity, changes in the blood system, etc.) that occur while taking certain medications should be monitored and, if possible, prevented.

Before starting therapy, an explanatory conversation should be held with the patient and his relatives that the treatment can be long-term, and the reduction in pain will occur gradually. For neuropathic pain, even with the right treatment program, it is rarely possible to achieve 100% pain relief. Thus, the doctor must in a certain way form adequate expectations of the patient and his relatives regarding treatment. Some studies have shown that a reduction in pain intensity by 30% from the initial level according to VAS is assessed by the patients themselves as a satisfactory result. This figure should be kept in mind when assessing the effectiveness of the treatment.

Before prescribing any new drug for the treatment of neuropathic pain, a careful analysis of the drugs already taken by the patient is necessary to exclude drug interactions. A potential interaction between opioid analgesics and tricyclic antidepressants has now been described, causing serious adverse events in overdose. If such a combination is used, the benefits and risks of this prescription must be carefully weighed. Most tricyclic antidepressants, anticonvulsants and opioid analgesics have a depressant effect on the central nervous system. In order to reduce the severity of these and other side effects, gradual titration from the minimum (for example, 1/4 tablet of amitriptyline containing 25 mg) to the maximum tolerated dose over several weeks is necessary in the process of achieving an effective dose. In this case, the doctor and patient must understand that pain relief will be gradual. Because tricyclic antidepressants and carbamazepine are rapidly metabolized in some patients, monitoring of drug plasma levels is required before it is safe to further increase the dose if the lowest dose does not provide analgesia.

Summarizing what was said above about the pharmacotherapy of neuropathic pain, it should be especially emphasized that, despite the certain effectiveness of the drugs of the above-mentioned different drug groups, neuropathic pain is not included among the indications for the use of most of them. The exceptions are the following: gabapentin and pregabalin are registered for the treatment of peripheral and central neuropathic pain, carbamazepine is registered for the treatment of trigeminal neuralgia only.

Character, manifestations, associated problems

Neuropathic pain can be of a different nature - pain, tingling, burning. It can occur periodically or be present continuously for a long time, creating significant discomfort and worsening the quality of life. Sometimes it is accompanied by partial numbness of parts of the body, even a decrease in the normal functioning of the affected limbs - for example, the hand becomes weaker, the fingers are less controlled, etc.

In a number of advanced cases, even symptoms such as increased pain when clothing or a draft touches the affected area, thinning and flaking of the skin, degenerative processes in the subcutaneous tissue, disturbances in the temperature of the affected area of ​​the body, disturbances in the growth and structure of hair, nails, etc. These signs indicate that the autonomic part of the nervous system is also involved in the pathological process.

Symptoms and treatment of neuropathic pain in adults

Neuropathic pain is a pathological condition in which a person experiences physical suffering for a long time. It differs from ordinary pain in that it is caused by damage to one of the areas of the nervous system. The defective area sends incorrect signals to the brain, to which it reacts sharply.

For example, a patient squeezed a spoon with his fingers, but because of the disease, the brain thinks that it is some kind of sharp or hot object. This distortion of perception leads to the fact that the fingers begin to feel tingling or heat.

Etiology

Due to defects in the functioning of the nervous system, excitability at the level of the peripheral apparatus decreases. In this case, structures are activated that transmit an erroneous signal about pain to the brain.

The causes of neuropathic pain lie within the human body. There are a number of infections and disease conditions that cause neuropathic pain.

Here are some common causes and factors of neuropathic pain:

• diabetes mellitus - increased blood sugar levels lead to nerve damage. 50% of diabetic patients experience neuropathic pain. It is felt as a burning sensation in the feet, provoked by wearing closed shoes. This problem is called “diabetic polyneuropathy”;
• herpes rashes - older people who have had herpes zoster are more susceptible to neuropathic pain than others. The duration of the pain syndrome is 3 months. Unpleasant sensations are concentrated in the area of ​​the rash. Along with them, there is an increase in skin sensitivity;
• spinal cord injuries – lead to damage to the spinal cord, which causes pain. The most intense pain sensations are concentrated in one place, while slight tingling sensations are noted throughout the body;
• stroke - it may take several years after a stroke before neuropathic pain occurs. Damage to the brain nerves causes coldness in the hands and causes periodic chills;
• surgical intervention - the nerves at the site of dissection do not always restore their full function. This leads to periodic tingling and numbness;
• spinal injury - pain persists even after the damage has healed. The patient feels lumbago that begins near the lower back and pierces the body to the very feet;
• elbow joint injury - neuropathic pain as a result of an elbow joint injury often plagues athletes who hold their arms up, as well as people doing physically demanding work;
• radiation - radioactive radiation in large doses has a detrimental effect on the nervous system, causing neuropathic pain;
• Chemotherapy - Chemotherapy drugs act aggressively on both cancer and healthy cells. They cause disturbances in the functioning of the nervous system. After chemotherapy is stopped, neuropathic pain remains;
• limb amputation - there are widespread cases where people continue to experience pain and tactile sensations in the amputated limb. This phenomenon is called phantom pain. The mechanism of their occurrence is not fully understood. Apparently it involves the brain sending a signal to a non-existent part of the body;
• Trigeminal neuralgia - this disease leads to the fact that a person experiences neuropathic pain when touching objects. Chewing and swallowing are also accompanied by discomfort;
• HIV and AIDS - acquired immunodeficiency syndrome causes multiple damage to the nervous system, which is why defects can occur both in the peripheral and central nervous systems.

Type of neuropathic pain

Depending on the intensity of pain and their location, the following types of neuropathic pain are distinguished:

1. Moderate pain - burning and tingling occurs in the upper and lower extremities. It does not cause physical pain, but causes psychological discomfort with its persistence.

2. Pressing pain - burning or tingling appears in the legs. Untreated lower extremity neuropathy progresses and leads to gait problems.

3. Short bursts of pain . They feel like a sharp spasm, which after a couple of seconds moves to another part of the body.

4. Increased sensitivity of the skin . Physical contact with any surface leads to unpleasant sensations and pain at the point of contact. This forces the patient to sleep in the same position, and also to refuse clothing made of thick fabrics.

There are two phases of neuropathic pain: acute and chronic.

The acute phase is characterized by attacks of stabbing sensations that quickly pass. Chronic neuropathic pain manifests as mild tingling sensations during the day that lead to sleep disturbances at night.

According to statistics, 7 out of 100 people suffer from some type of neuropathic pain. In recent years, the number of people with this disease has increased. This is due to the fact that detection and diagnosis methods have improved.

Symptoms

Neuropathic pain is accompanied by impaired skin sensitivity. It manifests itself in the form of pain in response to stimuli that do not cause such a reaction in a healthy person.

This phenomenon is called “allodynia” and can have both mechanical and thermal origin.

In the first case, pain occurs due to touching or pressing on the skin. Thermal allodynia is caused by exposure to heat or cold. This manifestation of neuropathic pain is not eliminated by analgesics and intensifies at night.

The patient experiences pain when covering himself with a blanket or wearing clothes.

In addition to allodynia, the following symptoms of neuropathy are noted:

• decreased muscle strength. Without proper treatment, muscles decrease in volume over time. Physical therapy is designed to combat this;
• causeless goosebumps and numbness. There is a feeling as if insects are crawling on the skin;
• feeling of coldness in the hands and feet. Chills may occur;
• regular occurrence of pain for six months or more;
• discomfort when touching the surfaces of objects, decreased or increased sensitivity. Over time, the unpleasant sensations develop into full-fledged neuropathic pain.

Source: https://tvojajbolit.ru/nevrologiya/simptomyi-i-lechenie-neyropaticheskoy-boli-u-vzroslyih/

Not just pain

The problem for treatment is the late visit to the doctor on this occasion - most people suffering from neuropathic pain cite a period of a year or more from the first noticeable manifestation before treatment. By this point, due to constant suffering, disorders such as insomnia, depression develop, and neuroses and anxiety states intensify. This causes chronic fatigue, daytime sleepiness, decreased reaction speed and concentration.

Neuropathic pain is often associated with the development of the disease, but its intensity is not always directly related to the degree of damage to the nervous system, and treatment of the underlying disease does not always relieve neuropathic pain.

Neuropathic pain can develop as a result of damage to both the central and peripheral nervous systems, as well as when the sympathetic nervous system is involved in the pathological process.

Treatment options

Today, thanks to numerous research and developments in the field of neuropathic pain therapy, a large number of methods are known to combat the described phenomenon. It should be borne in mind that the methods of treating this problem depend on its specific type. At the same time, therapy for the syndrome requires a complex intervention, including drug therapy, physiotherapeutic interventions, as well as additional tools of influence. It is for this reason that types of therapeutic manipulations are described below, with the help of which you can forever forget about the described type of painful sensations.

Medicines that reduce pain

Typically, groups of drugs are determined by the type of pain, so the diagnostician must differentiate the phenomenon so that the treatment is as effective as possible. For constant pain, expressed in the form of tingling and burning, analgesics can be prescribed, which in turn are very effective for this type of pain. Acetaminophen or Aspirin can be used as pain relievers.

Under certain conditions, it is appropriate to prescribe non-steroidal drugs, which helps relieve inflammation, but the effectiveness of taking these drugs is not always present. If the pain is severe, the doctor may recommend using stronger analgesics, for example: Hydrocodone, Oxycodone or Codeine.

Tricyclic antidepressants are part of the treatment process and are aimed at reducing the intensity of pain. The most effective drugs are considered to be: Nortriptyline, Desipramine, Doxepin, etc. It should be understood that antidepressants can reduce a certain aspect of pain, but cannot eliminate it completely. In such a situation, even slight relief as a result of a medicinal approach is considered successful.

It is not uncommon to use ointment for local anesthesia. These are drugs for external use, among which it is worth noting Capsaicin, which depletes neurons, reducing their conductivity. Noticeable improvements after using the ointment occur after about a few weeks. You will need to apply the product 3-4 times during the day, which in the future will be an excellent method of reducing the severity of sensations.

How to relieve pain with exercise therapy

As an auxiliary approach aimed at restoring the functioning of the peripheral nervous system, leading experts insist on including physical therapy in the therapy program. It should be noted that moderate physical activity is not just a tool for treating neuropathic pain, but also an effective prevention that helps prevent exacerbation and relapse of the disorder.

Physiotherapy

Physiotherapy is an obligatory element of therapy for the described phenomenon, which largely helps to reduce the intensity of pain and also normalizes nervous activity. As a non-drug approach, a wide variety of methods for correcting the patient’s condition can be used. The main practice is massage and manual therapy, implemented in different directions. Hardware manipulations performed percutaneously in hospitals are also appropriate. Thus, treatment with electrical stimulation devices, lasers and acupuncture is successfully practiced.

Treatment with folk remedies

As part of traditional healing methods, blue or green clay is often used, which should be prepared in a special way before use. Raw materials need to be rolled into small balls, which are dried in the sun. You can store the blanks in a transparent jar, where they will feel very good. To carry out therapeutic manipulations, you need to dilute 20 grams of blue clay in 150 milliliters of warm purified water. You will need to drink the resulting mixture three times a day before meals for several weeks.

Common Causes

• diabetes;
• chronic deficiency of vitamins in the body, including those resulting from unbalanced therapy of diseases;
• radiculitis;
• oncological diseases;
• injuries;
• previous surgical and radiation interventions;
• alcoholism;
• AIDS;
• intervertebral hernia;
• regular overwork of certain muscle groups, leading to the development of the so-called tunnel syndrome, when chronic compression of nerves by muscles or tendons causes first discomfort and then pain.

Neuropathic pain is often characterized by changes in its nature. For example, they can often begin with a feeling of numbness, slight coldness, then give way to acute pain or a burning sensation, itching. The affected areas can enlarge and shift.

Neuropathic pain: causes and symptoms - About Palliative

Neuropathic pain is a companion to many human diseases. The cause of its appearance may be damage to various parts of the nervous system.

Such damage affects very different levels: from small nerves located deep in the tissues, to nerve trunks, plexuses, and even individual sections of the spinal cord and brain.

Since a person is riddled with nerves, damage to them at any level and site can lead to neuropathic pain.

If you've ever bumped your elbow or had a dentist hit a nerve with a drill while working on your teeth, you understand what neuropathic pain is. People with chronic neuropathic pain experience this feeling on a daily basis. At the first manifestations, patients describe this pain as discomfort, burning, “shooting”.

Causes

Neuropathic pain can be caused by a variety of factors, including fractures, metabolic disorders, and nerve damage during surgery. It can also be caused by a stroke, limb amputation, or spinal cord injury.

Neuropathic pain results from disruption of nerve structure and function. And it’s worth mentioning separately about nerve compression, for example, when a benign neoplasm puts pressure on the walls of nearby organs and brings pain due to overstretching of these walls.

Component or disease

Neuropathic can occur as an independent disease or accompany other diseases, for example, diabetes mellitus or coronary heart disease - then doctors talk about the neuropathic component.

Several types of pain can occur simultaneously. For example, neuropathic and nociceptive together. If a person breaks his arm, events can develop according to different scenarios.

The first case, when a fracture occurs and a muscle and ligament sprain occurs nearby, the person feels only typical nociceptive pain, which he describes as sharp, aching and throbbing.

Another case is when, during a fracture, the nerve bundle is stretched or the nerve is torn.

Even when the bone heals and the person has no external reasons to worry, he may experience pain from this damaged nerve. If the area of ​​damage was large, it is likely that the nerve will remain damaged forever and the person will deal with chronic neuropathic pain.

Stages of pain

With damage to the nervous system, pain develops quite slowly and gradually.

Typical situation –

the appearance of tunnel syndrome: nerves are compressed in narrow places by tendons, muscles or other structures located nearby.

This can happen on the neck, arms, legs due to awkward posture, tight shoes or clothing. Carpal tunnel syndrome often occurs in office workers who work in one position at a computer.

Pain terminology Basic terms and definitions in the topic of pain

Another situation is nerve irritation due to a herniated intervertebral disc, which is usually accompanied by aseptic inflammation and edema. At this stage, the nerve is only irritated or slightly compressed, but these effects do not go unnoticed and can cause severe pain and discomfort.

As the disease progresses, the second stage of neuropathic pain occurs. The nerve is compressed so that it ceases to perform its functions. Numbness appears in the area of ​​innervation of the compressed nerve, and the person’s surface sensitivity is impaired.

The third stage is loss of deep sensitivity. Muscle weakness appears; muscles innervated by damaged nerves refuse to work. As a result, muscle atrophy occurs.

You may have heard the phrase “the leg is withered” or “the arm is withered” - this, in fact, is muscle atrophy.

When a doctor observes a deficiency of nerve function in a patient, he understands that emergency release of this nerve is necessary - decompression.

The longer a person goes without treatment, the less chance there is of restoring nerve function after decompression.

And even if the doctor performs an excellent technical intervention, a person who has endured this pain for a long time may remain with it for life if the nerve is not restored.

Treatment begins with diagnosis

An important condition when making a diagnosis is the patient’s observation and his desire to cooperate in the selection of treatment, since it is important for the doctor to know exactly how the pain is felt, what provokes it, intensifies it, and alleviates it.

But sometimes even a specialized examination cannot determine the etiology of neuropathic pain, which makes the correct selection of treatment difficult.

According to doctors, such pain is most often associated with disturbances in the structure of the nerve and/or its compression, for example, as a result of tumor growth, due to the formation of a scar, or chronic overstrain of a group of muscles and tendons.

Therefore, for clarification, instrumental diagnostic methods may be prescribed, such as ultrasound, MRI or CT, which will detect disturbances in the structure of the nerve or its pathological compression.

Neuropathic pain in adults: causes and treatment

Attention! Self-medication can be dangerous to your health.

Neuropathic pain is not associated with dysfunction of any organ. It is not a signaling function indicating the development of a certain pathology. Neuropathic pain manifests itself against the background of damage to certain areas of the central or peripheral nervous system.

The nerve fibers themselves may be damaged, causing incorrect signals to be sent to the pain centers. A clear example of neuropathic pain is phantom syndrome. This condition is characterized by the fact that the amputated limb continues to hurt.

Neuropathic pain always causes persistent pain.

Symptoms and treatment of neuropathic pain in adults

Neuropathic pain is a pathological condition in which a person experiences physical suffering for a long time. It differs from ordinary pain in that it is caused by damage to one of the areas of the nervous system. The defective area sends incorrect signals to the brain, to which it reacts sharply.

For example, a patient squeezed a spoon with his fingers, but because of the disease, the brain thinks that it is some kind of sharp or hot object. This distortion of perception leads to the fact that the fingers begin to feel tingling or heat.

Therapy

Treatment of neuropathic pain is quite challenging. As already mentioned, it is not always possible to accurately determine the causes of pain. In this case, at a minimum, treatment is prescribed to alleviate the patient’s condition and reduce his suffering. If a connection is established between the disease, injury and neuropathic pain, therapy for the underlying disease is also prescribed.

Even sustained pain relief is considered a good result, because... intense and prolonged pain in itself becomes an additional factor in the deterioration of well-being and health, and decreased ability to work.

Notes

1. Danilov A.
   Neuropathic pain Neuromedia, 2003, 60 pages.
2. IASP Taxonomy - IASP (English) (inaccessible link - history
   ). www.iasp-pain.org. Retrieved May 2, 2020. Archived January 13, 2020.
3. Nicola Torrance, Blair H. Smith, Michael I. Bennett, Amanda J. Lee.
   The Epidemiology of Chronic Pain of Predominantly Neuropathic Origin. Results From a General Population Survey // The Journal of Pain. — 2006-04-01. — T. 7, issue. 4. - pp. 281–289. — ISSN 1528-8447 1526-5900, 1528-8447. — DOI:10.1016/j.jpain.2005.11.008.
4. ↑ 1 2 Turbina L. G., Gordeev S. A.
   DIAGNOSIS AND TREATMENT OF NEUROPATHIC PAIN. — Moscow, Russia: Moscow Regional Research Clinical Institute named after. M.F. Vladimirsky, Faculty of Advanced Medical Studies, 2014. - ISBN 978-5-98511-244-3.

Thoroughness and complexity are the key to effective therapy

For the purpose of treatment, complex therapy is often prescribed, combining several areas, and in such cases it is especially important to follow all prescriptions, including recommendations for the regimen. Some patients stop symptomatic treatment on their own, for example, stop taking painkillers prescribed by the doctor as soon as the pain subsides and ceases to cause severe anxiety. This should not be done - the maximum chance of success is provided by a well-chosen combination of all the necessary therapeutic methods.

If a doctor prescribes pain relief, then it is a necessary condition for treatment and in any case will improve the patient’s well-being and quality of life.

A blow to the nerves. Why do neuropathic pain occur?

Our expert is a neurologist, head of the department for the treatment of patients with acute cerebrovascular accidents at the Moscow Research Institute of Emergency Medicine named after N.V. Sklifosovsky, candidate of medical sciences Ganipa Ramazanov.
Over the past 40 years, the number of chronic pain syndromes has been increasing in the world. According to various estimates, they make up from 15 to 70% of all diseases. Therefore, pain clinics are springing up like mushrooms after rain. There are about four thousand of them in the USA. We have less, of course, but also a lot.

Better than a thousand words

Pain actually plays a dual role: it can be both harmful and beneficial. After all, this is an effective defense mechanism that protects us from dangers. She is a strict teacher - her “education methods” are completely unpedagogical, but very effective. After all, once experienced pain teaches us caution. And often it saves people’s lives, forcing them to see a doctor. In addition, pain is also an important clue for the doctor, facilitating the diagnosis. “Useful” pain is caused by irritation of pain receptors located in the skin, muscles, ligaments, and internal organs.

Signs of neuropathic pain

1. Severe pain in response to a harmless stimulus (eg, light touch, slight increase in temperature).
2. Burning, squeezing pain. Sometimes there is a feeling of goosebumps or tingling, as if from a weak electric shock. Or a constant burning sensation (often in the fingers and toes).
3. The pain does not go away for a long time even after the irritation stops. May be combined with decreased sensitivity, numbness, and a feeling of frostbite. The sore spot may become red, pale, or very swollen.
4. Short-term severe pain. Appears in fingers, toes and arms. Migrates frequently.
5. Chills.
6. Insomnia, increased anxiety, depression.

2. Causes of pain

There often seems to be no obvious cause for a patient's neuropathic pain. But doctors identify several types of common causes of such pain:

• Alcoholism;
• Amputation;
• Problems with the back, legs and hip area;
• Chemotherapy;
• Diabetes;
• Facial nerve problems;
• HIV infection or AIDS;
• Multiple sclerosis;
• Shingles;
• Spinal surgery.

Visit our Neurology page

It hurts and won't stop

But chronic pain that lasts more than three months teaches nothing and is not useful for anything.

It is caused not by external injuries or internal diseases, but by nerve damage. This kind of neuropathic pain, according to statistics, occurs in 6-7 people out of a hundred.

This “breakdown” causes the nerves to send excessive and incorrect signals to the brain, which reacts with severe pain. This happens with diabetes mellitus, herpes zoster, limb injuries, hernias in the spine and other diseases. Moreover, excruciating pain occurs for almost no reason - sometimes the friction of the body on clothes or bedding is enough. Patients experiencing debilitating neuropathic pain suffer from insomnia, depression, and often avoid communication even with family members. This pain is no longer a symptom, but an independent disease.

Forecast

Important! Neuropathic pain can negatively impact your life if you don't take steps to treat it and prevent symptoms from getting worse.

Over time, this can lead to serious disabilities and complications including depression, sleep problems, anxiety and more.

Fortunately, researchers are learning more about why this condition develops and what can be done to treat it effectively. This leads to better treatment options.

If you find an error, please select a piece of text and press Ctrl+Enter.

What does this mean?

Neuropathic pain often accompanies many diseases:

• Herpes (shingles). As a rule, there is skin sensitivity and severe pain around the body.
• Diabetes. There is a burning sensation in the feet and toes. Often the symptom appears at night.
• Stroke. There may be tingling, burning, or a feeling of extreme cold on the affected side of the body.
• Spinal cord injuries. Shooting, squeezing or stabbing pains may develop in the torso and limbs.
• Trigeminal neuralgia. Severe pain in the face when chewing or speaking. Occurs more often in older people.
• Spinal diseases. There may be quite strong sensations in the arms and legs.

As well as multiple sclerosis, AIDS, chemical or radiation exposure and some other diseases.

Phantom pain that occurs after amputation is also a type of neuropathy.

Learn more about the nature of neuropathic pain

Relation to neuropathic pain can be:

Allodynia. This means that the pain is triggered or worsened by touch that would not normally cause pain. For example, a slight coating on the face may cause pain if you have trigeminal neuralgia. The pressure of the bed sheets can cause pain if you have diabetic neuropathy.

Hyperalgesia. This means that you experience severe pain from contact that would normally cause only minor discomfort. For example, gentle pressure on a painful area can cause severe pain.

Paresthesia. This means that you experience unpleasant or painful sensations even when there is no touch stimulus. For example, you may experience a painful pinprick or electric shock sensation.

In addition to pain, the very impact pain has on your life can also be important. For example, pain can lead to sleep disturbances, anxiety and depression.

How often does neuropathic pain occur?

It is estimated that approximately 7 in every 100 people in the UK have persistent (chronic) neuropathic pain. It is much more common in older people, who are more likely to develop the diseases listed above.

Not just for depression

A qualified neurologist can help you cope with neuropathic pain. First of all, he will find out the root cause of the pain - that is, the disease associated with it. This is what needs to be treated first.

Medicines (usually not one, but several) can help eliminate the pain itself. Analgesics usually don't work. Anticonvulsants are more effective, as are antidepressants, which require at least six months to take. For very severe pain, narcotic painkillers are used.

Some people find physical therapy and acupuncture helpful. There are also the latest methods of therapy, in which special devices are implanted under the skin and, using electrical impulses, control the functioning of nerve endings.

Treatment

The goal of treating neuropathic pain is to identify the underlying disease that is responsible for the pain and treat it if possible.

An important goal is for the physician to strive to relieve pain and help maintain normal activities despite pain and improve the person's quality of life.

The most common treatments for neuropathic pain include:

Over-the-counter pain reliever

Nonsteroidal anti-inflammatory drugs (NSAIDs) are sometimes used to treat neuropathic pain.

However, many people believe that these medications are not effective for neuropathic pain because they do not target the source of the pain.

Prescription drugs

Opioid pain medications are generally not recommended because they do not relieve neuropathic pain but relieve other types of pain. Additionally, doctors may be afraid to prescribe them for fear that the person may become addicted.

Topical pain relievers can also be used to relieve pain. These include lidocaine patches, capsaicin patches, and prescription ointments and creams.

Antidepressants

Antidepressants have shown great potential in treating symptoms of neuropathic pain.

People with this condition are prescribed two types of antidepressants:

1. Tricyclic antidepressants.
2. Serotonin and norepinephrine reuptake inhibitors.

They can treat both pain and symptoms of depression or anxiety caused by chronic pain.

Anticonvulsants

Anticonvulsants are often used to treat neuropathic pain. Gabapentinoids are most often prescribed for neuropathic pain.

It is not clear why anticonvulsants work for this condition, but researchers show that these drugs interfere with pain signals and stop erroneous transmissions.

Nerve blocks

The doctor may inject steroids, local anesthetics, or other pain medications into the nerves believed to control pain signals. These blocks are temporary, so they must be repeated to keep working.

Implantable device

This invasive procedure requires a device to be implanted into the body. Some devices are used in the brain and some in the spine.

Once the device is installed, it can send electrical impulses to the brain, spinal cord or nerves. The impulses can stop nerve signals and control symptoms.

Important! These devices are usually only used by people who have responded poorly to other treatment options.

Lifestyle

Physical, relaxation, and massage therapy are used to relieve symptoms of neuropathic pain. These forms of treatment can help weaken the muscles.

For example, some people with neuropathic pain may experience an increase in symptoms after several hours of sitting. A physical therapist can teach you techniques for sitting, stretching, standing, and moving to prevent pain.

Neuropathic (neuropathic) pain: causes, symptoms, treatment (February 2020).

Overview of Neuropathy and Neuropathy

Neuropathy is nerve dysfunction that results in loss of sensation. Although many people develop neuropathy, a limited number of these people continue to experience pain associated with their symptoms. This condition is known as painful neuropathy and the pain is described as neuropathic pain.

The specific reason why pain develops with neuropathy is unknown. Several theories have been proposed. One theory suggests that when nerve cells are unable to conduct sensory impulses or messages, spontaneous activity begins in the nerve cells, which the brain interprets as pain.

Unlike pain that occurs in response to injury, neuropathic pain occurs without any associated stimulation. Sometimes neuropathic pain can be associated with exaggerated or hypersensitivity to normal stimulation (such as light touch or the feel of clothing), and these sensations can be misinterpreted as pain.

Pain is unique to everyone. Thus, the words used to describe neuropathic pain may vary. Common descriptions include tingling, stinging, burning, pricking or pain. The pain may be present on a constant basis, or it may be intensified and relieved by the wax. As described, pain is most often present without accompanying stimulation, but activities such as weight bearing can dramatically aggravate or worsen the pain.

Causes of neuropathy and neuropathic pain

There are many causes of neuropathy, ranging from diabetes (the most common cause of neuropathy in the United States) to exposure to toxins. Many diseases - not just diabetes - can be associated with the development of neuropathy, including HIV and kidney failure. Peripheral nerve injury can lead to neuropathy. Alcohol and tobacco can lead to neuropathy, and some prescription drugs can cause neuropathy. Shingles (herpes zoster) can cause pain in the nerve fibers affected by the rash. Once neuropathy has developed, pain can begin at any time. At this time, doctors cannot predict who will develop neuropathic pain. In fact, many people are unaware that they have neuropathy until the pain begins.

Characteristic clinical pattern of symptoms

The main symptom of neuropathic pain is a periodic feeling of burning, numbness or tingling, as well as pain. The localization of such sensations depends on the causes of their occurrence. In addition to the superficial feeling, the pain can penetrate deeper and be permanent.

Symptoms of neuropathic pain
Among the symptoms that are accompanied by the above unpleasant feelings are:

• sleep disturbance due to increased sensitivity and short-term pain;
• constant anxiety, which can develop into depression;
• decreased quality of life, which is directly affected by uncomfortable feelings.

Neuropathic pain is chronic. As we said, it appears, retreats, but then returns again. Patients suffering from this disorder constantly complain that the pain becomes unbearable at night.

Painful sensations affect not only the feet and hands. As a result of the disorder, the perception of external influences by the entire human body can change, which is why even a light touch causes pain.

The main symptoms of neuropathic pain are a burning sensation and numbness, as well as tingling and pain. The method of treating the disease depends on the reasons that caused it.

In adults

Patients experience the following pain symptoms:

• decreased muscle strength. If you do not pay attention to this, the muscles will become flabby. Physical therapy will help restore strength;
• numbness and goosebumps. There is often a feeling of coldness in the extremities and the sensation of insects crawling over the body;
• periodic manifestation of pain in the body. Each time the pain is repeated, it is felt with greater intensity;
• discomfort when touching objects or lack of sensitivity, developing into acute pain.

All this can lead to the appearance of associated symptoms, such as:

• severe stress;
• chronic insomnia;
• despondency and apathy;
• causeless irritability.

The patient himself cannot always understand the complexity of his condition, believing that it is just fatigue or incorrect body position when resting.

In children

In children, symptoms of neuropathic pain are difficult to notice immediately. The child does not understand the nature of the sensations, but tries to alleviate the condition by remaining in a more comfortable position, even if it does not seem very comfortable from the outside.

In this condition, children are not allowed to touch the sore area. In addition, they become lethargic, inactive and do not communicate well, without explaining their condition. In some cases, the child shows aggression, trying to distract himself from severe pain.

The search for a characteristic clinical pattern of symptoms is formulated in an algorithm called “The Three Cs in the Diagnosis of Neuropathic Pain.” It includes three actions.

Listening is the first step. It is necessary to be attentive to the words with which the patient describes pain. These are verbal descriptors that are characteristic of neuropathic pain. Such a combination of characteristics as “shooting”, “lumbago”, “tingling”, “needles”, “burning”, “burning”, “numbness” often indicates to the doctor neuropathic pain.

Watching is the second step. A neurological examination includes a study of sensitivity and analysis of sensory phenomena in the pain area. When the somatosensory zone is damaged, sensory disorders are observed, which are divided into negative symptoms (or symptoms of loss - spontaneous pain, dysesthesia, paresthesia, allodynia, hyperalgesia) and positive symptoms (symptoms of irritation - hypoesthesia, anesthesia, hypalgesia, analgesia).

Neuropathic pain is characterized by a combination of symptoms from both groups. The combination of these sensory phenomena is a sign of neuropathic pain. Another characteristic sensory sign of neuropathic pain that is important for diagnosis is allodynia, which manifests itself as a sensation of pain in response to a non-painful stimulus.

Relate is the third step. At this stage, it is necessary to determine whether the identified disorders are a consequence of damage to the nervous system. Verbal descriptors and the results of sensory analysis must correspond to a clear neuroanatomical zone - the root zone in radiculopathy, the zone of a specific median nerve in mononeuropathy, the zone of peripheral nerves in polyneuropathy, the segmental level in postherpetic neuralgia.

Thus, analysis of a set of specific verbal descriptors, the results of a neurological examination, and the reliability of the connection between the identified disorders and damage to the nervous system allows us to identify a characteristic pattern for neuropathic pain.

Additional tools for diagnosing neuropathic pain are the DN4, Pain Detect, LANSS questionnaires, which play a supporting role in analyzing the clinical picture of the pain syndrome.

Quantitative sensory testing, a technically sophisticated method of analyzing sensory phenomena, is also recommended for diagnosing characteristic neuropathic patterns. Quantitative sensory testing can assess pain, temperature, tactile and vibration sensitivity.

History of involvement or disease of the peripheral or central somatosensory nervous system

To diagnose a patient with neuropathic pain, it is necessary to analyze his medical history to identify nosologies that are most often accompanied by neuropathic pain syndrome. Diseases or pathological conditions such as diabetes mellitus, herpes zoster, nerve injury, root injury, plexus injury, stroke, spinal injury, multiple sclerosis, oncopathology most often have neuropathic pain in their clinical picture.

Why is pain treated with an antidepressant?

Many patients, after consulting a neurologist, are perplexed: why did he prescribe me an antidepressant? I’m a completely normal person, I’ve only been bothered by pain for a long time!

In this case, the antidepressant is most likely prescribed not for the treatment of a mental disorder, but specifically for the treatment of chronic pain. But how are antidepressants related to pain? Let's break it down and start by understanding what pain is and how it occurs.

Pain

is a negative emotional feeling associated with actual or potential tissue damage. It turns out that pain can be associated with damage (for example, injury or inflammation), or there may be cases when there is pain, but there is no damage.

Acute pain is often caused by a specific damaging factor, such as a cut finger or a sharp strain in the back muscles. An inflammatory process occurs, and when it subsides, the pain goes away. But there are cases when the pain becomes chronic, lasting more than 3 months, which exceeds the period of normal tissue healing.

Pain without damage?

Let us consider the structure of the sensitive nervous system in general terms using the example of its normal operation. receptors in our skin, muscles and tissues

– sensors that perceive information about damage and generate a pain impulse.
Pain impulses
pass through the nerve fiber, the pathways of the spinal cord and brain and ultimately reach the cerebral cortex, where awareness of the pain sensation arises.

Therefore, if a sensitive analyzer malfunctions at any level from receptors to the cerebral cortex, pain may occur.

This can occur in various neurological diseases: radiculopathy, polyneuropathy, stroke, and so on.

Causes of Neuropathic pain:

Signals arising from tissue damage (trauma, inflammation, pressure, heat, cold) are “read” by pain receptors (nociceptors) located on the skin, ligaments, muscles and internal organs. Pain impulses are transmitted along the nerves to the spinal cord, and from there to the brain, where they are recognized as pain. In neuropathic pain, nerve damage itself stimulates such impulses. The main causes are physical effects (pressure, overextension), toxic (alcohol), metabolic dysfunction (diabetes, vitamin deficiencies), viral infections (shingles) or inflammatory processes. Radicular pain can also be neuropathic when the nerve roots are pinched by a herniated disc. Nerve damage leads to the development of neuropathic syndromes, the most common of which are discogenic and vertebrogenic lumbar and cervical radiculopathies (34.7% and 11.9%), diabetic polyneuropathy (10.6%), trigeminal neuralgia (5.8%) , postherpetic neuralgia (4.1%).

Chronic pain

Chronic pain

occurs as a result of dysfunction of our own pain system.
The fact is that we have internal anti-pain mechanisms
that reduce the conduction of pain impulses in the nervous system.

And, interestingly, these mechanisms are associated with feelings of happiness.

Our body releases endorphins (internal opiates - morphine-like substances) as well as neurotransmitters such as serotonin and norepinephrine. These substances improve our mood and reduce the sensation of pain. That is why, when we do something we love and enjoy, which brings pleasure, pain disappears. Our anti-pain mechanisms are stimulated. How can we help them?

Adequate sleep, moderate exercise, communication with loved ones, doing things you love, walking in nature - all the things we enjoy - all this stimulates the release of endorphins, serotonin and norepinephrine.

Even the much discussed placebo phenomenon is not only psychological, it is based on the same biochemical processes and is the result of stimulation of analgesic mechanisms. "Placebo" translates to "I like." If the patient has a positive attitude toward treatment, trusts the doctor and believes in the effective action of the drug, then when he takes a dummy (a drug that actually has no therapeutic effect), pain decreases by 40%. The release of endorphins is stimulated. That is why if the patient takes naloxone (a drug that blocks the action of opiates) in advance, the placebo effect will not occur. Therefore, to stimulate our pain mechanisms, we must engage in activities that bring us pleasure.

Neuropathy and pain: means of relief

Content

I hear complaints about pain every day. People are very worried about:

• pain of any localization in acute leukemia;
• pain in the left hypochondrium with splenomegaly;
• pain when nerves are compressed by enlarged lymph nodes;
• ossalgia in myeloma.

In the latter case, the pain may be most pronounced; previously, many of these patients received narcotic analgesics. Now the results of treatment for multiple myeloma have improved significantly; morphine is practically not prescribed in my department. We cope with NSAIDs and tramadol.

Myeloma: pain with neuropathy

But I remember one case of pain syndrome for the rest of my life. The patient was born in 1951. Diagnosis: Multiple myeloma. Treatment was carried out according to a modern regimen, including bortezomib, cyclophosphamide, and dexamethasone. We managed to carry out 2.5 courses of PCT. Ossalgia has been relieved, bone pain is not a concern. But the 3rd course of PCT had to be interrupted due to severe peripheral neuropathy.

Bortezomib has such side effects, hematologists know about this, so they abandoned IV administration in favor of subcutaneous administration, since neurotoxicity is less pronounced. But this patient, despite subcutaneous administration, developed severe neuropathy. Which manifested itself as pain in the legs and feet. Bortezomib was discontinued, we prescribed her lenalidomide, but the pain progressed so much that it could not be relieved by any of the available analgesics.

This was the first time I encountered such strong manifestations. Of course, we prescribed therapy for neuropathy (α-lipoic acid, Milgama, Lyrica). Our consultant neurologist approved this, but the therapy did not bring any effect.

I thought that the reason was demyelination, she said that, apparently, axonopathy, but this is not important. The neurologist said it takes time, several months, perhaps six months. Every morning the patient complained that she had not slept all night and that she would “go so crazy.”

Pain and legal reform

At this time, we were undergoing reforms related to the transition from the Ukrainian right field to the Russian one. We were not allowed to have narcotic analgesics in the department, because... there was no equipped storage room. Then we decided that we would not prescribe drugs in our department, and that, if necessary, they would be prescribed and administered by anesthesiologists.

These reforms met with fierce resistance from anesthesiologists; they did not directly report to the head physician and chief of medicine. I was torn between the suffering patient and my colleagues, the bosses promised me that anesthesiologists would come and administer morphine, and the anesthesiologists answered that they could not leave 15 patients on mechanical ventilation.

How they docked

The patient asked for a stronger analgesic.

Not finding a way out of this impasse, I transferred the patient to intensive care, although she did not need any resuscitation measures, she only received morphine. The anesthesiologists were surprised: “Why is she lying here?”, but I wanted to send them all away.

After three days of morphine injections, her pain subsided, she returned to hematology, and then I discharged her home. At home she continued to receive analgesics, in my opinion, also morphine. Tramadol did not relieve her pain. Such an individual feature, I think.

The relatives turned out to be adequate, they didn’t blame anyone, they just asked: “When will this go away?” I urged them to be patient, explaining that over time their nerves should recover. It must be said that this usually happens, but in this case the pain decreased, but did not disappear completely throughout the observation of this patient.

What to do if you have severe pain

Your message about ossalgia clearly shows the unexpected possibility of a painful hyperreaction with extremely excruciating pain. Which can lead the patient to psychosis and suicide, with the formation of chronic pain.

Without going into detail, first of all, the central mechanisms of the occurrence of such a hyperreaction (the phenomenon of neuronal inflation, NMDA excitotoxicity, etc.), albeit against the background of existing and maintaining pain neuropathy, this reaction can be compared to a fire. And the rapid spread of fire - a fire that then smolders for a very long time.

And here it is recommended to quickly and to the maximum extent (even if later it will seem to someone that they are shooting at sparrows with guns) to try to relieve the pain. In our anesthesiology, this is multimodal analgesia (morphine, seduxen, NSAIDs, paracetamol all together and at once).

We do not limit the doses, of course, within reasonable limits and are prepared for possible respiratory depression and a drop in blood pressure. Sometimes this is not enough and you have to use regional blockades (here they would be very useful for pain in the feet and ankles). Midazolam is prescribed to maintain medicated sleep. Sometimes we use ketamine as an NMDA receptor antagonist.

Maintenance antipain therapy

Then take a few days off the medication, the lyrics are good, for psychotic reactions, if you’re lucky, tizercin. This approach makes it possible to significantly block the transition of acute neuropathic pain to chronic pain. But it is important as soon as possible - immediately and as much as possible. You will think - well, the anesthesiologist got carried away, he ran away, we only have NSAIDs and tramal.

But there is an OAR and it is very correct that you transferred the patient there. It’s just that anesthesiologists need to explain what the transfer is for, they need to understand. In general, throughout the civilized world there is a pain service, and here and there we have pain wards.

Pain problem

The problem of pain, especially chronic pain, is very relevant and, in principle, can be solved quite well. But when our evil guys consider doctors drug dealers and patients drug users, what can we say? Although it is good to remember the words of Dupuytren: “pain, like bleeding, kills a person” and “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens, Art. 30, paragraph 5: When seeking medical help and receiving it, the patient has the right to ... relief from pain associated with the disease and/or medical intervention, in accessible ways and means.”

Scheme

Pathophysiologically, this situation can be represented as:

1. predisposition to pain due to multiple myeloma complicated by neuropathy,
2. the administered drug as a pain trigger due to the activation of algogens (prostaglandins, cytokines, histamine, etc.) in the bones,
3. the formation of hyperalgesia with peripheral nociceptor (for which NSAIDs are needed) and central neural (+ opioid analgesics, paracetamol) components,
4. transformation of hyperalgesia into neuropathic pain with the involvement of limbic structures - psycho-emotional component (+ benzodiazepines, pregabalin),
5. Chronication of pain with insufficient relief from the very beginning. Schematically something like this. I present it in order to show the validity of complex therapy for this fire.

You very accurately noted about caring, I would also add empathy for pain with the patient. These are almost entirely intuitive feelings. And if a colleague has them, you can almost always find mutual understanding with him regarding the patient, sometimes with diametrically different views.

You can evaluate the material:

0 (0 votes) / out of 5 on Severe pain due to neuropathy

You can share it via social networks:

And also leave a comment.

Article: Severe pain with neuropathy Updated: 11/01/2017 admin Comments: 2 comments

Chronic pain and antidepressants

But if the pain is chronic, then this is no longer enough; it is necessary to add medications.

It has been found that certain antidepressant drugs that increase the concentration of serotonin and norepinephrine can have an analgesic effect.

It is in connection with their analgesic activity that antidepressants are prescribed for chronic pain. Much lower dosages of drugs are used than in the treatment of depression. Modern antidepressants are well tolerated and lack withdrawal symptoms. After completing the course of taking the drug, the patient calmly stops taking the drug.

It is precisely because of their effectiveness and fairly good tolerability that antidepressants are included in clinical and international recommendations for the treatment of chronic pain syndrome, neuropathic pain, chronic migraine, chronic tension-type headache, chronic nonspecific low back pain, fibromyalgia and other diseases.