Neuropathic Pain by Dr. Andrea Furlan

My name is Andrea Furlan and I am pain
specialist in Toronto Canada, today we’re going to talk about neuropathic pain.
With my experience of 25 years working in pain clinics and with patients who
have chronic pain I can say that the worst descriptions that I hear about
pain and chronic pain are from patients who have neuropathic pain. I
remember a patient who had had a stroke and he described his pain has burning
oil on all the left side of his body. burning oil constantly dripping on all
of his left side of his body. I also remember a patient who had diabetic
neuropathy and the way he described his pain was like ants crawling his legs
all day long, constantly and he could not do anything for those ants go away. A
very well-known painter Frida Kahlo, she had neuropathic pain and she painted
her pain and if we see one of her paintings. This is called the broken
column it’s a self-portrait from 1944. We see that she painted her spine has a
metal rod, she also painted her torso has been a metal corset always squishing her back and her abdomen. And she also painted some pins and needles all
over her skin, and that was constantly causing this tingling in her skin. So
how do we define neuropathic pain? Neuropathic pain is defined as pain that is
caused by a disease or injury of the nervous system and we know that the
nervous system is composed of a peripheral and a central nervous system
the peripheral nervous system is formed by the nerves, the peripheral nerves and the central nervous system is basically the spinal
cord and the brain. So neuropathic pain can originate from the peripheral
nervous system or the central nervous system, the examples of some of the
peripheral neuropathies that can cause neuropathic pain are diabetic neuralgia, post-herpetic neuralgia, trigeminal neuralgia, carpal tunnel syndrome,
HIV neuropathy, and alcoholic neuropathy The central neuropathies can be things
caused by stroke like a central post stroke pain or after brain injury,
multiple sclerosis, spinal cord injury. Those are some examples of Central
Neuropathic pain. We know that neuropathic pain affects 8% of the general population. How do we make the diagnosis of neuropathic
pain? So basically the diagnosis is by examining the patient in talking to the
patient and we call the signs and symptoms. So some of these symptoms that the patients will complain that they will tell us about pain. The pain
descriptors are very characteristic of neuropathic pain. These are usually
described as tingling. Tingling is like pins needles pricking. Like the patient
that I mentioned to you that describe to me the ants crawling in his skin
that’s what we call tingling. Patients will also refer the pain as hot or burning
they may also describe his shooting pain or electrical shocks or they may talk
about stabbing or cutting like a knife entering the skin. Those are the
descriptors of pain. Other sensations also that are common and related to the
neuropathic pain can be numbness or lack of sensation in an area of the body. Also
they may describe the touching that area is painful so normally if we touch
someone it doesn’t cause pain but when that happen we call that allodynia. Also they may describe intolerance to cold to extreme
cold. They can’t tolerate cold applied to the skin or even cold weather. When we
examine the patient we are looking for signs in the physical exam that will
identifying some neuropathy and these are typical signs in neuropathic pain so
for example reduce sensations. If we examine the patient’s and they have
reduced sensation to pain we call that hypoalgesia, but they may also have
reduced sensations they may not feel pressure, heat, cold, touch, we call that
hypoesthesia. Or there might be augmented, elevated sensation they may feel more, we call that hyperesthesia or hyperalgesia. Or there
might be cross sensations, we may touch the skin with a stimulus that cause
touch and the patient may say this is pain so that’s a cross sensation and we
call that allodynia. We may also examine the rest of the nerve system we
need to examine for the reflexes the motor is strength to see if we can
identify what is the underlying neurological condition that is causing
that neuropathic pain. And I have to say that in many cases we can’t find what is
causing the neuropathic pain and those are the difficult cases because it’s if
it’s not diabetes if it’s not post- herpetic neuralgia, then it’s hard even for us to treat but in many cases we can find a cause for the neuropathic pain. In other
cases we may also order all the tests like skin biopsy, nerve biopsy or
electromyography in nerve conduction studies. So how do we treat neuropathic pain? We use a variety of modalities: pharmacological, no
pharmacological. We are going to talk a little bit about those. In terms of drugs
or pharmacological, we may use anti- depressants like the tricyclic, antidepressants SNRI like duloxetine venlafaxine. We may also use
anticonvulsants like carbamazepine, gabapentin, pregabalin. We may also use
opioids like tramadol or a stronger opioids. We may also use cannabinoids. And other things that we can also prescribe are things like vitamins, especially
vitamin B. We can also use the mo- drugs like physical modalities such as
what my patient found the warm water. We can prescribe them like warm baths or
TENS machines which is some electrical stimulation to the skin. We can also
prescribe topical creams things like capsaicin or lidocaine or ketamine
creams. We can also do some injections botulinum toxin type A or nerve blocks.
And also complementary and alternative medicine things like acupuncture,
manipulation, they work well for some types of neuropathic pain especially
peripheral nerves like carpal tunnel syndrome. Other things are mind-body therapy like CBT, hypnosis, mindfulness Those things are very helpful. And when we see a patient with neuropathic pain we have to tell them there are many modalities
not only medications that can help with your neuropathic pain and you have to
put them in a toolbox. Remember the toolbox for treatment of
chronic pain and you may have seen that exercises is not in this toolbox of
treatment of neuropathic pain. It’s not because I forgot it it’s because
exercise is usually not very helpful to treat the neuropathic pain. Although we
tell people to continue doing exercises as tolerated, any kind of exercise that
they like to maintain their body in shape and also to avoid all the types of
pain which can be myofascial pain that could aggravate the neuropathic pain.
Our first goal when we see someone with neuropathic pain is to ask how they are
sleeping, and we try to help their sleep and we try to do this with medications
or relaxation or mindfulness because people with neuropathic pain is very
common that they can’t sleep well, and if they can’t sleep well they are always
more stressed, they may gain weight they are more anxious more depressed so we
need to tackle the sleep problem right away. And I like to mention also that
there are some types of neuropathic pain that can be prevented, things like
vaccines for varicella-zoster or reducing alcohol intake to avoid
alcoholic neuropathy, controlling the blood sugars in people who have diabetes
is also a good idea, and things like wearing helmets to avoid brain injury
because I see some patients who had neuropathic pain because of a traumatic
brain injury. Remember that this video is not intended to provide individual
medical advice. If you think that you have neuropathic pain and you need
medical treatment please consult your physician to get a treatment plan for
you. This video is only for educational purposes. And if you like this video
don’t forget to like it, to write your comments, write your questions and I will
prepare more videos in the future to answer your questions I also have a
tweet and Instagram account and a Facebook page you can also contact me
there. Thank you for watching. Bye

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