Improving Neuropathic Pain
I received a request from a reader to address sciatica. She has been suffering severe chronic pain from this condition. Rather than address just sciatica, I thought I would address the broader topic of neuropathic pain or “neuralgia.”
Neuropathic pain is just that – pain that originates from the nerves themselves. This pain is usually related to some type of physical injury to nerve(s) but sometimes the nerves can just malfunction and act as though they have been injured. Common causes of neuralgia other than physical trauma include diabetes, herpes virus infections (shingles or Zoster), nerve compression, and cancer. Many cases are “idiopathic,” meaning there is no identifiable cause.
The pain can be precipitated or worsened by things such as touching or rubbing the skin, wearing clothing over the affected area, pressure from things such as bed sheets, or just having air blow over the skin. Some people just have constant pain with no apparent precipitating factors.
Neuropathic pain is perceived quite differently from the pain one experiences when touching something hot or hitting one’s thumb with a hammer. Patients usually describe it using one or more of the following: “burning,” “pins & needles,” “electric shocks,” or a “severe toothache.” The pain can be so severe that patients contemplate suicide. The brain has difficulty sorting out this type of pain because the nerve messages it receives not only involve typical pain, but also the non-pain sensations of touch, temperature, etc.
This pain can be extremely debilitating and frustrating for the patient and their family as well as their doctor(s). It’s a very complex disorder that often doesn’t improve with one particular treatment and may require a multidisciplinary pain team approach. This team might include doctors (primary care, neurologists, neurosurgeons and pain management specialists) as well as other health professionals (physical or occupational therapists, psychologists, etc.).
There are numerous treatments available for neuralgia. Traditionally, physicians have used various types of medications including antidepressants, and anticonvulsants (medications to treat seizures). Antidepressants are often used in low doses and appear to block the movement of pain messages to the brain. Anticonvulsant medications reduce the rapid-fire nerve impulses that are seen with neuropathic pain. Some patients with unrelenting pain may also require narcotic medication.
Non-drug treatments can also be quite helpful. One such modality is TENS, which stands for “Transcutaneous Electrical Nerve Stimulation.” This consists of wearing one or more pairs of electrode patches on the skin attached to a box that generates electrical pulses. The box is worn on the belt or in a pocket. The electrical impulses generated by the TENS unit serve to block the pain messages going up the spinal cord to the brain. A more permanent way to deliver these pulses is to surgically implant a nerve stimulator next to the spinal cord.
Other treatments that have been shown to be effective include anesthetic injections, behavioral therapy, and biofeedback. Creams containing capsaicin can be helpful. The nutritional supplement alpha lipoic acid has been shown to have some benefit in treating diabetic neuropathy.
As you can see, this is a very complex problem and one that is often not responsive to one single treatment. It may take months or years of trying various different modalities, either singly or in combination to improve neuropathic pain.
Dr. John Roberts is a retired member of the Franciscan Physician Network specializing in Family Medicine.