The document discusses various types of neuropathic pain, their causes, symptoms, and current best practices for management, including pharmacological and non-pharmacological treatments. It highlights the emotional impact of chronic pain on patients, the effectiveness of therapies such as spinal cord stimulation and action potential simulation therapy (APS), and reviews recent research findings on pain relief methods. The document also emphasizes the importance of tailored treatment approaches and the potential benefits of alternative therapies in improving quality of life for individuals suffering from chronic pain.

1.  
Current best practice
& innovation

3.  ”…Having had neuropathic pain for nearly all my
life I am not the person I should have liked to
have been…It is truly the loneliest place there is,
when you are trying to smile through gritted
teeth at well meaning people who have
absolutely no idea what you are going through.
Going off to their busy lives while I and
thousands of others go and lie down and miss
out on so much living…”

4. Nociceptive
Inflammatory
Neuropathic
Functional

8.  Neuropathic pain may arise as a consequence of a
lesion or disease affecting the somatosensory system

9. Neuropathic pain is
caused by
A lesion or disease in the
somatosensory nervous
system
Peripheral nervous
system
Central nervous system

10. ‘Central’ rather than ‘peripheral’.
Post-stroke – 8%
Multiple Sclerosis- 25%,
Spinal Injury – 40-50%
Traumatic Brain Injury

11. General population studies, using validated screening instruments, have found that
7–8% of adults currently have chronic pain with neuropathic characteristics.

12.  Burning
 Electric shocks
 Shooting
 Sharp
 Tingling
 Buzzing
 Stabbing
 Pins &
needles
 ‘Sunburn’

13.  Spontaneous pain – no evident stimulus
 Allodynia – stimulus not normally painful
 Hyperalgesia – increased response to painful stimuli
 Dyasthesia – unpleasant abnormal sensation
 Parasthesia – abnormal sensation – buzzing, tingling

14.  Hypoasthesia – diminished sensitivity to touch & pain
 Anasthesia – total loss of sensation
 Hypoalgesia – diminished pain with painful stimuli
 Analgesia – absence of pain in response to painful
stimuli

15. IASP Factsheet – Mechanisms of Neuropathic pain

16.  ‘Central neuropathic pain is associated with emotional
distress and lower health-related quality of life and
affects rehabilitation, mood, sleep, and social
functioning’. – IASP 2014

17. Pharmacological
Oral, topical
Injection Surgical – TGN,
discectomy
Neuromodulation
SCS, PNS,
MCS,deep brain
Intrathecal drug
delivery
Psychological
therapies
Electrotherapies
acupuncture
Physical
Therapies

18. • Pregabalin:up to 600mg
• Gabapentin: up to 3,600mg
Anticonvulsants
• Amitryptilline – 10 – 150mg
• Duloxetine – 60mgAntidepressants
• Localised pain, & cannot
tolerate/wish to avoid drugs
Topical capsaicin

19.  Firstline for trigeminal neuralgia – carbamazepine
 Tramadol as short term rescue therapy
 Lidocaine patches for hyperalgia/allodynia
 Less sedating antidepressants – nortryptilline,
imipramine
 Combination therapy

20. Clomipramine, Dosulepin (dothiepin) Doxepin,
Lofepramine, Trimipramine
Citalopram, Escitalopram, Fluoxetine, Paroxetine,
Sertraline, Mirtazapine, Reboxetine
Trazodone, Venlafaxine, Lacosamide, Lamotrigine
Levetiracetam, Oxcarbazepine, Phenytoin
Valproate, Topiramate, Buprenorphine
Co-codamol, Co-dydramol, Dihydrocodeine
Fentanyl, Morphine, Oxycodone, Oxycodone with naloxone
Tapentadol, Cannabis sativa extract, Flecainide
5-HT1-receptor agonists

21.  Gabapentin &
Pregabalin – voltage
gated calcium channel
blockers
 Amitryptiline – SNRI, &
sodium, calcium and
voltage gated
potassium channel
blocker

25.  All sensation takes place by nerve transmission
 Nerve transmission relies on action potentials

26.  Resting potential… all gates closed.Cell negative charge
 1) chemical gated channels open, allow sodium Na+
in…charge rises inside cell…
 2) voltage gated channels open, allow sodium in, rises…
 3) Cell depolarises – action potential – wave travels
down axon..+ charged potassium rushes out…
 4) at synapse, + = voltage gated calcium channels open
 5) Stimulates release of neurotransmitters
 = Action, movement, feeling, thought, pain
 Cell repolarises

28.  Anticonvulsants: somnolence, weight gain, dizziness,
peripheral oedema, headache, dry mouth, blurred vision,
diploplia, dysarthria, abnormal co-ordination, parasthesia
 Also: sexual dysfunction, constipation, vomiting,
flatulence, memory impairment, vertigo, increased
creatine kinase level, memory impairment, increased risk
of depression & suicidal thoughts and behaviours.

29.  common : dry mouth, constipation, dizziness, blurred
vision, urinary retention, drowsiness, palpitations,
orthostatic hypertension, sweating.
 Also linked to: cognitive disorders, confusion, gait
disturbance, falls
 Recent research shows causative link to dementia in
long term use ( 2 years low dose)
Cumulative Use of Strong Anticholinergics and Incident Dementia A Prospective Cohort Study
Shelly L. Gray,et al JAMA Intern Med. Published online January 26, 2015. doi:10.1001/jamainternmed.2014.7663

30. Electrotherapy –
TENS
Psychological therapies –
CBT
Mindfulness
Self-hypnosis

31.  SCS modifies the perception of neuropathic and
ischaemic pain by stimulating the dorsal column of the
spinal cord.

32.  Effectiveness: evidence for Failed Back Surgery Syndrome
(FBSS) and Chronic Regional Pain Syndrome (CRPS)
 >18 yrs
 failed back surgery syndrome
 complex regional pain syndrome
 neuropathic pain
 chronic pain measuring >5/10 on VAS for 6 months +
 have tried and not responded to conservative treatments
 stop/reduce excessive medication, pain mg’ment strategies
 be able to manage the technical demands of the equipment.
 Successful trial demonstrating 50% pain relief

33.  pain that will not benefit from spinal cord stimulation
 (widespread pain syndromes)
 anatomical problems eg spinal deformity, extensive spinal
metalwork,scar tissue in the epidural space
 active infective illness
 chronic medical condition ( eg MS, COPD)
 psychiatric illnesses
 very high or very low BMI
 use alcohol, prescription drugs, and/or recreational drugs
excessively
 allergy to nickel or any other components of the implantable
device.

34.  Effective in 5-7/10 cases
 Evidence in Failed back surgery syndrome & CRPS
 2010; £14,500 per patient NHS (East Midlands
Specialised commissioning group)
 Private: 2015; Spire Roding, East London, £23,000
 Problem of adaptation/tolerance

35.  Peripheral nerve stimulation -
 Not routinely funded
 Oxford Radcliffe have 85% success in 75% reduction
 Motor cortex stimulation – electrodes on surface on
brain
 Post-stroke pain
 Atypical varieties of trigeminal neuralgia

36.  Deep brain stimulation – ‘DBS involves stereotactic
targeting of specific anatomical sites within the brain
(such as the sensory thalamus or periaqueductal grey
matter) to modulate the central processing of pain signal
Small risk of death, CVA,
infection
Cost £30,00 OIRO
21% failure rate
‘even partial relief of their pain
had resulted in significantly
improved quality of life.’

37.  ‘Pump’

38.  The technique of intrathecal drug delivery (ITDD) is
based on the principle that effective analgesia can be
achieved by the action of some drugs at the dorsal horn
and adequate concentrations cannot be achieved by
systemic administration, or only by high systemic doses.
Delivery of the drug by the intrathecal route is a means
of achieving these enhanced therapeutic effects. The
smaller doses needed for intrathecal administration also
allow a reduction in side effects compared to systemic
administration. -- British Pain Society 2008
 2009: NHS £12,771 per patient – East Midlands
Specialised Commissioning group

40. •
•
•
•
•

•
•
Dr. Lia van der Plaat, Dove
House Hospice, Hull UK

51.  Specific waveform
simulates Action
Potentials

52.  Does not block channels
 ?Restores effective nerve transmission
 Enhanced removal of waste products
 Boosts production of ATP = speeds injury repair & body’s
own healing mechanisms
 Cellular repair and regeneration enhanced
 Faster wound and injury healing
 Improved recovery time after exercise
 Pain relief
 Better quality of sleep
 Enhanced energy

55.  storage and distribution vehicles of energy
 adenosine, ribose, and three molecules of phosphate.
 Energy is released when the phosphate bond is broken.
 Function: convert glucose, from food, into energy.
 more ATP = better function and more energy

56.  Melatonin: significantly raised sedative, anxiolytic,local
vasodilation & anticoagulation, limitation of tissue damage at sites of
inflammation due to the effects on prostaglandins and free oxygen radicals.
 Leukine enkephalin: progressively increased
 Effective analgesic due to interaction with opioid receptors as well as
inhibition of substance P (the neurotransmitter responsible for pain
transmission). • Limitation of tissue damage at sites of inflammation and/or
hypoxia. • Increase in pulse rate and systemic blood pressure, associated
with peripheral vasodilation, which results in better perfusion at the affected
areas. -

57.  Beta-endorphins: significantly decreased
 Cortisol: unchanged but uninhibited
 Neurohormonal Consequences of APS TherapyProf. Dr.
J.M.C. Oosthuizen MBCHB; DMEDSCI University of the
Free State;Prof. Dr. E.H. de Wet MBCHB; MMED; MD

58.  Growth hormones, cellular repair secreted stages 3 & 4

59. TENS
Alternating current
Foreign pulse
Gate theory pain relief
Endorphin on ‘tapping’
mode
APS Therapy
Direct current
Biological frequencies
Stimulating ATP, detox,
injury repair
Benefits accrue and are
more lasting
No accomodation

60.  An assessment of APS Therapy on 285 Patients with Chronic Pain in 2002
reported a mean average VAPS was 6.8 before treatment and 3.3 after
treatment in the over 50s, and 6.3 and 2.2 respectively in the under 50s. Out of
the 285 patients,44 (15%) ended with a ‘0’ VAPS and 199 (69%) with a score of
5 or less. (1)
 A trial of APS Therapy in patients awaiting or having neurosurgery for intractable
spinal pain concluded that the number of patients treated was too low to reach a
statistical conclusion, but that the trend was very promising and they
recommended that patients waiting for destructive surgery should first be put on
a thorough trial of APS Therapy.(2)
 In a 1999 randomized, patient blinded, placebo-controlled study, on 76 patients
with chronic osteoporotic back pain, reported pretreatment baseline VAPS value
average of of 57.79, and post- treatment value after the sixth treatment of 9.7
(p= 0,0001); 6 patients maintained benefits 6 months post treatment.(3)
 A study in 1999 on APS Therapy compared with TENS in 99 patients with
osteoarthritis of the knee did not find a significant difference between the two
treatment groups given just 6 treatments over a 2 week period. The authors did
note, however, that the APS group showed a significant improvement in
measures of knee flexion and swelling, which persisted even 1 month after the
last treatment. (4)

61.  1) Papendorp DH van. (2002). Assessment of Pain Relief on
285 patients with chronic pain. Biomedical
Research 2002; 26: 249-253.
 2) Du Preez, J. Neurosurgical Pain Conditions University of
Pretoria
 3) Odendaal & Joubert APS Therapy- a new way of teating
chronic backabacke, a pilot study South African Journal of
Anaesthesiology and Analgesia.1999; 5 1
 4) Berger, P. Matzner, L Study on 99 patients with
osteoarthritis (OA) of the knee to investigate the effectiveness
of low frequency electrical currents on mobility and pain:
Action Potential Simulation therapy (APS) current compared
with transcutaneous electrical nerve stimulation (TENS) and
placebo.South Africa Journal of Anaesthesiology and
Analgesia

62.  42 people began the course
 6 dropped out
 1 x Migraine
 1 x Vomiting
 1 x Discouragement after 2 weeks
 1 x Visual disturbance
 2 x Ill with pre-existing medical condition

66.  Counted as 1 whole point on the VAS
 Average improvement overall was 4.7 points
 12 people reduced or discontinued medication
 Could have been more, hadn’t planned

67. Average VAS pre: 6.3 Average post: 2.5

70. Pre – mean 5.1 post mean 2.2. Actual results quite polarised

73. 2 x muscle fatigue type pain – no result
1 x post pin and plate – no result
1 x psoriasis pain
– good result
1 x varicose vein pain
– good result

74.  Increase in energy, reduction in fatigue x 4
 Reduction in swollen legs & ankles x 2
 Alleviation of life-long insomnia x 2
 Cessation of recurrent UTIs x 2
 Improvement in circulation & discolouration
 Reduction of ‘fatty lump’ on hip
 Disappearance of swollen glands on neck
 Cessation of ‘fluid on skull’ sensation
 Reduction in dizziness & improved cognitive function

77.  ““I’ve not felt like this since I was about 15! For two thirds of
my life, I’ve been in some kind of pain, with lack of energy, not
sleeping properly, having to plan essential things that I need
to do, and then struggling to get them done, and frequently
cancelling appointments because I’ve not been well enough to
make them. Now, it’s my fourth week, and I’ve been active
every day for the past 2 weeks. For instance, 3 weeks ago,
my mum came to visit, and we walked everywhere, and then I
had to spend Monday in bed. 2 weeks ago, a friend came to
visit, we did the same walking, but the next day I was just up
and active at 6/7 am. Now I’m sleeping well at night, and
nothing is such an effort any more. I want to bottle it and give
it to everyone I know!”

78. www.painfreepotential.co.uk
01908 799870
miranda@painfreepotential.co.uk
Beds & Northants MS Therapy Centre
www.APSTherapy.com is HQ in Holland
Training monthly in Bedford, at your base
or individually using conferencing software
Thankyou very much