Neuropathic Pain Presented At Primed 5.11.09

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Neuropathic Pain

Causes, Mechanisms and Treatment of Neuropathic Pain

Presented At Primed, QE2 Conference Centre, Westminster, London to National Audience of Primary Care Doctors

5th November 2009

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Neuropathic Pain Presented At Primed 5.11.09

  1. 1. Neuropathic Pain<br />Dr. Christopher A. Jenner MB BS, FRCA<br />Consultant in Pain Medicine, Imperial Healthcare NHS Trust<br />Medical Director London Pain Consultants and Spinal Healthcare<br /> 5th November 2009<br />VXXXX<br />Date of preparation October 2009<br />
  2. 2. Agenda<br />Definition<br />Neuropathic v. nociceptive <br />Physiology<br />Epidemiology<br />Diagnosis<br />Management options<br />www.londonpainconsultants.com<br />
  3. 3. Definitions (1)<br />Pain. ‘An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage, or both.’ (IASP 2001)<br />www.londonpainconsultants.com<br />
  4. 4. Definitions (2)<br />Time-course:<br /> • acute <br /> • chronic<br /> www.londonpainconsultants.com<br />
  5. 5. Definitions (3)<br />Type:<br /> • nociceptive <br /> • neuropathic<br /> www.londonpainconsultants.com<br />
  6. 6. Nociceptive Pain<br /> www.londonpainconsultants.com<br />
  7. 7.
  8. 8.
  9. 9.
  10. 10.
  11. 11.
  12. 12. Neuropathic Pain<br /> www.londonpainconsultants.com<br />
  13. 13.
  14. 14.
  15. 15. Pain Physiology <br /> www.londonpainconsultants.com<br />
  16. 16.
  17. 17. Noxious Stimulus<br />
  18. 18. Pain Physiology<br />(boring)<br />www.londonpainconsultants.com<br />
  19. 19.
  20. 20. Noxious Stimulus<br />
  21. 21. Impulse Transmission<br />
  22. 22. Afferent sensory fibres<br />
  23. 23. Spinal cord<br />
  24. 24. Dorsal Horn<br />
  25. 25. Synapse<br />
  26. 26. Ca and Glutamate<br />
  27. 27. Synaptic Cleft<br />
  28. 28. Post Synaptic<br />
  29. 29. Nociceptive Neuron<br />
  30. 30. Pain perception<br />
  31. 31. Brain<br />
  32. 32. Neuropathic Pain<br />
  33. 33. Aetiology of NP<br />I<br />N<br />V<br />I<br />T<br />E<br />D<br />A<br />M<br />P<br />C<br />
  34. 34. Aetiology of NP<br />Infection<br />Neoplasia<br />Vascular<br />Iatrogenic<br />Trauma<br />Endocrine<br />Drugs<br />Autoimmune<br />Metabolic<br />Psychiatric<br />Congenital<br />
  35. 35. Neuropathic pain : Classification<br /> Peripheral<br />Neuropathies <br />(e.g. diabetes, alcohol)<br />Post-operative nerve injuries<br />Herpes zoster<br />Trigeminal neuralgia <br />Amputations<br />Plexus avulsions<br />Spinal cord<br />Spinal injury<br />MS<br />Tumour<br />Arachnoiditis<br />Syrinx<br />Brain<br />Stroke<br />MS<br />Tumour<br />Epilepsy<br />Syrinx<br />Jensen T. 2007<br />
  36. 36. Neuropathic pain syndromes<br />Peripheral<br />Chemotherapy-induced neuropathy<br />Complex regional pain syndrome<br />HIV sensory neuropathy<br />Neuropathy secondary to tumour infiltration<br />Painful diabetic neuropathy<br />Phantom limb pain<br />Postherpetic neuralgia<br />Postmastectomy pain<br />Trigeminal neuralgia<br />Central <br />Central post-stroke pain<br />Multiple sclerosis pain<br />Parkinson disease pain<br />Spinal cord injury pain<br />Dworkin R.H. A overview of Neuropathic pain: Syndromes, Symptoms, Signs and several Mechanisms<br />Clin J Pain (2002) 18:343-349<br />
  37. 37. Epidemiology of Neuropathic Pain<br />The Neuropathy Trust<br />
  38. 38. Epidemiology of Neuropathic Pain<br /><ul><li>Prevalence of 2-4% in UK
  39. 39. Over 30% neuropathy prevalence in diabetes
  40. 40. Predicted by 2010 ~ 1 million diabetes sufferers with neuropathy
  41. 41. Up to 70% neuropathy patients experience pain</li></ul>The Neuropathy Trust<br />
  42. 42. Neuropathic Pain in Primary Care<br />Common after surgery?<br /><ul><li>1 in 6 experience post mastectomy phantom pain
  43. 43. 1 in 7 experience post-thoracotomy neuralgia
  44. 44. 1 in 8 experience severe post herniorraphy pain
  45. 45. 1 in 33 experience phantom tooth pain after extraction</li></ul>Macrae WA. Chronic pain after surgery BJA 87 (2001) 88-98<br />
  46. 46. How Common is Neuropathic Pain in Primary Care?<br />Epidemiology of conditions (per 100,000 person yrs)<br />Post Herpetic Neuralgia = 40 ↓<br />Trigeminal Neuralgia = 27<br />Phantom Limb Pain = 1 ↓<br />Painful Diabetic Neuropathy = 15 ↑<br />Hall G. et al. Epidemiology and treatment of neuropathic pain: The UK primary care perspective.<br />Pain 2006; 122: 156–162 <br />
  47. 47. Clinical features of Neuropathic Pain<br />
  48. 48. History<br />Pain description- <br />burning/ shooting/ stabbing/ electric shock/ lancinating/ severe/ constant…..<br />Local hypersensitivity- <br />allodynia/ hyperalgesia/ dysaesthesia<br />Dysfunction<br />
  49. 49. Examination<br /><ul><li>Check for:
  50. 50. Allodynia (mechanical, thermal & punctate)
  51. 51. Skin changes (autonomic activity)
  52. 52. Sensory disturbances
  53. 53. Cold
  54. 54. Pin
  55. 55. Vibration
  56. 56. Soft touch</li></li></ul><li>Diagnostic & Screening Tools<br />
  57. 57. All based on use of pain descriptors and simple examination<br /><ul><li>LANSS scale Bennett, 2001
  58. 58. Neurop. Pain Questionnaire Krause, 2003
  59. 59. DN4 Bouhassira, 2005
  60. 60. ID Pain Portenoy, 2006
  61. 61. Pain Detect Freynhagen, 2006</li></ul>Diagnostic & Screening Tools<br />
  62. 62. LANSS Questionnaire<br />
  63. 63. Items Common to all Screening Tools<br />Bennett et. al. Using screening tools to identify neuropathic pain<br />Pain 127 (2007) 199–203<br />
  64. 64. Pharmacological Treatment<br /> • WHO analgesic ladder (abridged)<br /> • + tramadol<br /> • + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD<br /> (New: sufentanyl TDD/ product X)<br />www.londonpainconsultants.com<br />
  65. 65. Pharmacological treatment of Neuropathic Pain<br />www.londonpainconsultants.com<br />
  66. 66. Neuropathic Pain Management<br />Antidepressants <br />Amitryptilline<br />Anticonvulsants<br />- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate<br />Opioids<br />Local Anaesthetics/Analgesics<br />Lidocaine/ EMLA<br />www.londonpainconsultants.com<br />
  67. 67. NMDA antagonists<br />Sympatholytics<br />GABA –ergics<br />Capsaicin<br />www.londonpainconsultants.com<br />
  68. 68. Future Agents for Neuropathic Pain<br />Ziconotide (sea snail, conus magnus)<br />P2X3- (purine) receptor antagonists (ATP) (knockout mice)<br />Epibatidine (Equadorian poison dart frog)<br />Morphine and ketamine<br />Regular gabapentin<br />www.londonpainconsultants.com<br />
  69. 69.
  70. 70.
  71. 71. Lidocaine plaster v. Pregabalin in PHNBaron et al., 2009: Study overview and design<br />* according to SmPC<br />Baron et al., (2009) CMRO. 25: 1663-1676.<br />
  72. 72. Baron et al., 2009: Results – PHN<br />NRS-3 response rate after 4 weeks, Per protocol (PP)<br />Baron et al., (2009) CMRO. 25: 1663-1676.<br />
  73. 73. Baron et al., 2009: Results – PHN<br />Subject-based adverse event (AE) evaluation, Safety population<br />* p = 0.0020 * * p = 0.0001<br />Baron et al., (2009) CMRO. 25: 1663-1676.<br />
  74. 74. Physical and Alternative Treatments<br />
  75. 75. Physical and Alternative Treatments<br />Graded desensitisation<br />Mirror box therapy<br />Rehabilitation<br />
  76. 76. Psychologically based therapy<br />
  77. 77. Pain Management<br />Psychological<br /> CBT<br /> Operant Conditioning<br /> Psychoanalysis<br /> Relaxation<br /> Biofeedback<br />• Psychiatric<br />www.londonpainconsultants.com<br />
  78. 78. Pain Management Programmes<br />Medication <br /> • Goals (SMART- specific/ measured/ agreed/ realistic/ timed)<br /> • Coping<br /> • Contingency<br /> • Pacing<br /> • Education<br /> • Pain Behaviours<br /> • Reinforcementwww.londonpainconsultants.com<br />
  79. 79. Advanced Pain Management Techniques<br /> www.londonpainconsultants.com<br />
  80. 80. Nerve Stimulation<br />
  81. 81. Nerve Stimulation (2)<br />
  82. 82. Intrathecal Pumps<br />
  83. 83. The Future?<br />Demographics<br />Healthcare advances<br />↑ Patient expectations and involvement<br />www.londonpainconsultants.com<br />
  84. 84. Summary<br />Incidence of NP increasing<br />Nociceptive v neuropathic<br />Management of NP in primary care<br />When to refer <br />www.londonpainconsultants.com<br />
  85. 85. Summary<br />Very common (1 in 7 UK)<br />Time course- acute n chronic<br />Nociceptive and neuropathic<br />Multiple treatment modalities<br />www.londonpainconsultants.com<br />
  86. 86. Case reports/ Blogs/ Links/ Appointments<br />dr.jenner@satellitesec.co.uk<br />0845 045 0250<br />www.londonpainconsultants.com<br />
  87. 87. Any Questions<br />

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