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After reading the article you should be able to:

1. Describe the characteristics of neuropathic pain.
2. Discuss the terms of the pain management contract.
3. Compare and contrast the components of the various treatment modalities for neuropathic pain.

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By ELLEN BARKER, MSN, APN, CNRN, CLCP, ABDA

ELLEN BARKER is an advanced practice nurse in private practice, a neuroscience specialist, and the president of Neuroscience Nursing Consultants in Greenville, DE. The author has no financial relationship to disclose. STAFF EDITOR: MARTHA K. RAYMOND, RN, BSN, BS

The 60 year-old male patient with a history of neuropathy of the feet complains to the nurse that he has burning, sharp, stabbing foot pain that he describes as between eight and nine out of 10 in intensity. He tells the nurse that he has become depressed, as the symptoms seem to be getting worse even though he is taking the prescribed pills. He has difficulty walking, problems sleeping at night, and daytime fatigue, and has become almost totally dependent on his family. This patient is seeking relief from a diagnosis of the chronic nerve disorder referred to as idiopathic neuropathy, a condition that can cause persistent neuropathic pain.

Pain is a highly prevalent patient complaint, particularly for patients with a history of certain neurologic illnesses and trauma. Patients recovering from these disorders seek to regain lost function, become more active, and return to independence as soon as possible. Not everyone completely recovers from an acute disorder; patients often suffer pain that becomes chronic and superimposed on the neurologic disorder. This pain may become classified as neuropathic pain.

NEUROPATHIC PAIN Nurses involved with managing the care of neurologic patients need to clearly identify patients with neuropathic pain, as well as individuals who suffer this painful syndrome without any identifiable cause. Individuals with chronic neuropathic pain superimposed on their illness may experience major barriers to their recovery and rehabilitation. They may also suffer from this under-recognized syndrome without any identifiable cause. Early and accurate identification of neuropathic pain is therefore imperative as part of a thorough assessment and the development of therapeutic strategies for successful management. A significant barrier, however, has been that neuropathic pain is misunderstood due to a lack of education, which leads to inadequate treatment.

This article will help nurses become knowledgeable about a chronic pain disorder affecting an estimated 20 million people in the U.S. Successful management of neuropathic pain requires heightened awareness of and familiarity with the challenges and shortcomings of various treatments. Developing an effective plan of care can ensure that patients have better outcomes and an improved quality of life.

Full caregiver knowledge of neuropathic pain can lead to realistic therapeutic goals, acceptance of the analgesic regimen, and the ability to manage any adverse effects during treatment.

PATIENTS' RIGHTS Patients have a right to pain relief, yet too many patients continue to experience unrelieved neuropathic pain. Many nurses have not received formal education in managing this type of pain. It's therefore important for nurses to become competent
in neuropathic pain assessment, the pharmacological therapies available, and the implementation of a plan of care to prevent undertreatment and undesirable adverse side effects or complications.

Nurses are the frontline healthcare providers in helping the patient achieve comfort and reach functional goals as they recover from neurologic disorders that result in neuropathic pain. They are the key to helping patients overcome common myths, such as fears of addiction and drug dependence, as well as promoting a safe and effective individualized neuropathic pain management plan.

THE ROOT OF NEUROPATHIC PAIN Neuropathic pain is a heterogeneous, complex condition. The International Association for the Study of Pain defines neuropathic pain as initiated or caused by a primary lesion or dysfunction in the nervous system.¹

Neuropathic pain can be acute or chronic. The characteristic dysesthetic or abnormal quality of neuropathic pain is described in further detail in the "Characteristics of Neuropathic Pain" and can be the basis for key questions during assessment.

Neuropathic pain may result from injury to both divisions of the nervous system. The central nervous system (CNS) includes the brain and spinal cord, and the peripheral nervous system (PNS) includes parts of the nervous system located outside the cranial cavity and vertebral column, which is made up of 12 pairs of cranial nerves, 31 pairs of spinal nerves, and peripheral nerves.

In response to tissue damage, neurotransmitters such as somatostatin and pain-producing substances are released into the extracellular fluid surrounding the pain fibers. These substances may include bradykinin, serotonin, histamine, potassium ions, norepinephrine, prostaglandins, cholecystokinin, leukotrienes, and a compound known as substance P that may promote pain.³

There are two types of neuropathic pain that can be identified by the nurse: peripheral and central.² Peripheral neuropathic pain syndrome (PNPS) may be a result of chemotherapy-induced neuropathy, diabetic neuropathy, trigeminal neuralgia, alcoholic polyneuropathy, or carpal tunnel neuropathy. In addition, complex regional pain syndrome from trauma of an extremity is a type of PNPS.³

In contrast, central neuropathic pain syndromes (CNPS) may include central post-stroke pain that can take days or years to occur. A stroke on the right side of the brain appears to be the most commonly involved location. Although the cause is unknown, there are some theories that the pain may be related to an autonomic response.

The central nervous system is also responsible for pain due to multiple sclerosis, Parkinson's disease, spinal cord injury, and nerve compression. Phantom limb pain can result from an amputation, and pain due to syringomyelia is based on a spinal cord cyst. Radiculopathy is a type of nerve root irritation, especially in the cervical, thoracic, or lumbosacral areas.³ Other etiologies that may cause neuropathic pain are in the "Etiologies of neuropathic pain". Neuropathic pain is unique in that not everyone with pain due to a specific etiology experiences it in the same way. Pain can become a disease, versus a symptom.

This can frustrate patients and nurses during assessment. Some patients may experience a stimulus-evoked neuropathic pain from a thermal or vibration stimulus. Others may describe their pain as spontaneous, continuous, or intermittent.

MISCONCEPTIONS Patients may receive inappropriate pain management due to misconceptions because clinicians don't fully educate them on the subject. Patients may refuse prescribed treatment due to unfounded fears of narcotic or opiates. Patients with inadequate education about their treatment plan may express fear of medication side effects or the long duration of medication therapy. Without a thorough explanation of their unique neuropathic pain syndrome, patients may fail to recognize its two significant hallmarks.

The dominant characteristic is allodynia, or pain caused by a non-noxious stimulus to normal skin. This is sometimes referred to as a stroking hyper-algesia. Allodynia could include pain from someone simply touching thepatient's skin or from bed linen touching the patient. The second most common characteristic is hyperalgesia, a significantly increased pain response to a stimulus that is normally painful.³

CHRONIC PAIN SYNDROME Neuropathic pain is considered a chronic pain syndrome. It is important to recognize the characteristics of chronic pain in comparison to acute pain. Chronic pain is long-lived pain that is often described as persisting beyond three to six months following a specific cause.³ Once the pain becomes chronic, the pain has no adaptive biologic role and may occur without an apparent cause. In other words, it serves no protective purpose. Some clinicians often view a patient with chronic pain as a failure of medical care when the injury appears healed but the patient continues to complain of pain.

Patients often state that their quality of life is diminishing because the pain controls their life. Eventually, pain may be associated with psychological responses such as depression. This explains why nurses checking vital signs usually don't report the increases in heart rate, respiratory rate, or blood pressure typically associated with pain. Patients or their partners may report sleep disturbances, followed by personality changes such as irritability, demanding behavior, and other negative behaviors.

During patient treatment, nurses and care providers often document when patients fail to respond well to prescribed opioids. The response to pain-relieving treatments may vary and appear inconsistent. Episodes of regression in recovery are common. Nurses and treating clinicians may classify patients with neuropathic pain as representing their patient population as "outcome failures" and the most difficult to treat.⁴

NURSING CARE To conduct an appropriate pain assessment for neuropathic pain, multiple skills and knowledge are required. A comprehensive history should include substance abuse and treatment that may alert the nurse to follow up with drug screening. Patients with neuropathic pain may also report spasticity. The frequently applied zero-to-10 pain scale may not be completely accurate in identifying neuropathic pain and must be reinforced by additional assessment.

Questions explore the characteristics of a patient's pain, such as sharp, cold, and hot. It is important for the nurse to distinguish acute pain from chronic pain, and specifically neuropathic pain. A 10-item neuropathic pain assessment and other clinical tools specifically for pain education can be found on the Web site www.painedu.org.

Assess for allodynia, dysthesia, hyperalgesia, and paroxysmal response. Perform specialized sensory mapping to locate any areas for sensory loss. Complete a motor status exam to elicit for muscle weakness or atrophy. Check for swelling, skin discoloration, or trophic changes.

After determining that the individual has neuropathic pain, determine the best course of action. Not every patient will need referral to a pain treatment team or a facility. Patients who have failed to get relief from conventional oral medications and those with complex symptoms may be best treated in a pain clinic or by an experienced pain team that can offer a wide range of treatment techniques.

A multidisciplinary approach for diagnosis and treatment may be the preferred method of chronic neuropathic patient management. Typically, the pain team consists of a pain physician, nurse, anesthesiologist, psychologist/psychiatrist, pain counselor, neurosurgeon, physiatrist/rehabilitation team, social worker, pharmacist, dietitian, and case manager. Collectively, they can offer a comprehensive, integrated approach to assessment, and treatments that maximize function, increase coping, decrease dependence on medications, and offer long-term follow-up.

Nurses treating patients with neuropathic pain may collect an extensive pain questionnaire, and ask patients to keep a pain diary or tape recorder for documentation and sign an agreement. The nurse can review past diary entries that include morning, midday, and night reports of pain severity, medications, rescue doses needed for breakthrough pain, side effects, and how pain has affected the patient's activities of daily living. Nurses may encourage patients to keep a journal, draw sketches, or write about their experiences.

These activities often serve as a catharsis. Copies can be placed in the patient's records for review and to alert the team if the pain has become overwhelming and demands immediate attention.

Following the initial assessment, the first step may include diagnostic studies such as CT scans and magnetic resonance imaging as well as electrophysiologic and nerve conduction studies to locate the neurologic lesion, diagnose the underlying nervous system disorder, and determine the extent and precise location of the pain.

After evaluation of test results and each team member's individual assessments, the pain management plan is completed and presented to the individual. A pain management agreement spells out the pain team's commitment to comply with the law regarding controlled pharmaceuticals and outlines the patient's responsibilities. This agreement builds trust and confidence between members of the treating team and the patient. For example, the patient's signature reinforces compliance, agreement for substance abuse testing, and termination of pain-control medicines if the agreement is broken.⁴

TREATMENTS Neuropathic pain is difficult to treat; therefore, management protocols have to balance pain relief with side effects. Initially, the nurse may recommend non-pharmacologic treatment options. Nurses provide education on behavior modification and how to alter the environment to decrease pain. Cognitive-behavioral therapies are also part of non-pharmacological therapy and include distraction, imagery, relaxation, hypnosis, or biofeedback.

Rest, sleep, and the use of appropriate positioning, assistive devices, comfort measures, and support groups to promote the patient's confidence in taking charge of their condition are also part of a comprehensive care plan. The rehabilitation team can offer therapeutic modalities, exercises, heat/cold therapies, transcutaneous electrical nerve stimulation (TENS), and other modalities.³

Pain therapy may include first-line medications such as gabapentin (Neur-ontin), 5% lidocaine patch (Lidoderm), or transdermal fentanyl (Duragesic). Options may include common analgesics, non-steroidal anti-inflammatory drugs (NSAIDS), oral opioids, anticonvulsants, nerve blocks, epidural corticosteroids, antidepressant, topical agents, rehabilitation modalities, chiropractic therapy, and psychological rehabilitation. Various types of pharmacologic pain therapies can be used concurrently. For example, an opioid can be used with an NSAID or gabapentin, as well as other drugs specific to neuropathic pain.

A more extensive list of medications is in the "Commonly PresCribed mediCations". Considerations are needed for the elderly, who are often undertreated. Be aware that the elderly may need lower dosages and are at higher risk for developing renal toxicities, gastrointestinal bleeding, or other complications.

Guidelines for pain management may or may not follow the basic principles outlined by the World Health Organization three-step analgesic ladder familiar to most nurses.³ Nurses may first need to help patients overcome reluctance to follow their pain plan out of fear of addiction, side effects, long-term medication use and dependence, or cultural or religious beliefs.

Patients who fail to respond may be further evaluated for invasive therapies, such as surgery, intrathecal drug delivery (IDD) system, and spinal cord stimulation.² Often, these types of patients suffer with some type of central neurologic disease. However, neuropathic pain is responsive to IDD, which employs fully programmable implanted pumps that infuse medication directly into the cerebrospinal fluid (CSF) using an indwelling catheter. The IDD system is used in selected patients when oral medications fail, or if the patient becomes intolerant to escalating doses that are causing undesirable side effects. Direct delivery to pain sites of such medication as preservative-free morphine, hydromorphone (Dilaudid), fentanyl, or ziconotide (Prialt) has been demonstrated to be a safe and effective route. Medications are delivered at considerably smaller doses, and systemic side effects are eliminated. Ziconotide, the latest FDA-approved IDD, is derived from a snail toxin that works on the calcium channels.⁶

The system is nondestructive and can be totally reversed. As with any invasive, long-term implanted device, the patient will need to comply with drug refills, be taught to recognize the signs and symptoms of side effects, learn about the signs of drug overdose or under-dose, recognize the signs and symptoms of infection, and be aware of device malfunction.

Neuroablation involves the destruction of neural tissue. Examples of this treatment are cordotomy and dorsal root entry zone procedures. Surgical interventions are permanent and not reversible. If surgery is the patient's best option, it may eliminate the need for an implanted device or regular, continuous physician follow-up.

Spinal cord stimulation (SCS) may be an option for selected patients with chronic pain, and delivers a precise, programmed amount of electrical current to the dorsal spinal cord. The current causes individuals to experience paresthesias in the area of their pain, interrupting the perception of pain. SCS is considered when optimum medical management has failed to restore function and relieve pain if there is no radiological evidence of a deformity, lesion, or progressive motor deficit for patients 18 years of age or older. It first requires a screening trial of about one week with an externalized lead wire equipped with a temporary external transmitter. The SCS is implanted if the patient experiences a 50% minimum pain reduction via Visual Analog Score and tolerates the paresthesia, the area of paresthesia is concordant with the area of pain, and the patient demonstrates functional improvement.

Instead of repeat surgery, SCS may be an option for patients with neuropathic pain from failed back surgery. Past studies have estimated that 10% to 40% of patients who have lumbosacral surgery to alleviate neuropathic pain experience persistent or recurrent pain.⁵ A recent Canadian study, known as the PROCESS study, found that SCS provided far better pain relief than conventional medical management for chronic neuropathic pain that follows "failed back surgery."⁵

PATIENT OUTCOMES Over time, in the case of the 60-year-old with neuropathic feet, he received physical and massage therapy, and TENS therapy. His doctor, in collaboration with the nurse, also ordered special shoes with inserts. Medications prescribed included a long list of mild and moderate analgesics and opioids, such as oral methadone, ibuprofen (Motrin), hydromorphone (Dilaudid), fentanyl (Duragesic), tizanidine (Zanaflex), and zolpidem (Ambien) for sleep. Regardless of the oral medications or drug combinations, the pain intensity increased, the pain relief decreased and was associated with increased fatigue, apathy, and depression.

The patient was assessed and successfully screened for IDD.² He underwent surgery for catheter placement and pump implantation. After minor adjustments in dose and medications, his pain was reduced by greater than 50%, and he stated adequate pain relief. He has been stabilized on a combination of morphine and ziconotide IDD. He receives drug refills scheduled about every four months and has enrolled in a PT program with low-impact exercises, realizing that his former state of inactivity was counterproductive. The therapists encouraged him to walk daily and enroll in an aquatic aerobic class at the local health club to improve circulation and help strengthen nerve tissues and increase blood flow to his feet. His quality of life and functional capacity have improved remarkably, and he has resumed activities that he never imagined possible. He no longer takes any oral opioids and only needs oral analgesics for occasional breakthrough pain.

No one should have to suffer from untreated or inappropriately treated neuropathic pain. It can become a source of disability and even a disease of its own. Neuropathic pain is difficult to treat and is a distinct challenge to nurses and the healthcare team. Thorough assessment and skilled management of neuropathic pain are essential. Comprehensive care by the nurse requires knowledge of the treatments available and the ability to teach the patient how to live and cope with chronic nerve pain. Nurses should seek to identify the social, emotional, economic, and physiologic impact of neuropathic pain during acute hospitalizations and plan for long-term treatment of this painful, debilitating condition.

References

1. International Association for the Study of Pain. (2007). IASP Pain Terminology. Retrieved Dec. 2, 2008. http://www.iasp-pain.org/AM/Template.cfm?Section=Home&template=/CM/HTMLDisplay.cfm&ContentID=6648#Neuropathic

2. Barker, E. (2005). A new approach to chronic pain. RN, 68(5), 32ac1-5.

3. Barker, E. & Willens, J. S. (2008). Management of the neuroscience patient with pain. Neuroscience nursing: A spectrum of care. (3rd ed.). St. Louis:Mosby/Elsevier.

4. Dworkin, R. H., O'Connor, A. B., et al. (2007). Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain, 132(3), 237 – 251.

5. Kumar, K., Taylor, R. S., et al. (2008). The effects of spinal cord stimulation in neuropathic pain are sustained: A 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery: online, 63(4), 762-770. Retrieved Dec. 10, 2008. http://www.neurosurgery-online.com/pt/re/neurosurg/abstract.00006123-200810000-00027.htm;jsessionid=JQddnPWjS4RTxpNyD8MvxmBXsvkJQdpm
l1TPmn2QLJ1GZJX3K8rR!-1157250347!181195628!8091!-1

6. Mechcatie, E. (March 1, 2005). Marine snail toxin approved to treat severe pain. Internal Medicine News. Retrieved Dec. 10, 2008.

Characteristics of Neuropathic Pain

» Radiating, spreading pain

» Electric-shock-like sensation

» Hot, burning pain

» Shooting or stabbing/lancinating pain

» Paresthesia: numbness, tingling, feeling pins and needles

» Pain to light touch

» Extreme sensitivity to ordinarily innocuous stimuli

» Usually independent of movement

Source:

1. Barker, E., & Willens, J. S. (2008). Management of the neuroscience patient with pain. Neuroscience nursing: A spectrum of care. (3rd ed.). St. Louis: Mosby/Elsevier.

Etiologies of neuropathic pain

» Infections

» Diabetes mellitus: painful diabetic neuropathy (PDN)

» Traumatic injuries

» Diseases affecting peripheral nerves, e.g., post-herpetic neuralgia (PHN)

» Metabolic abnormalities

» Chemotherapy: chemotherapy-induced polyneuropathy

» Radiation

» Neurotoxins

» Inflammation

» Tumor infiltration

Source: Barker, E., & Willens, J. S. (2008). Management of the neuroscience patient with pain. Neuroscience nursing: A spectrum of care. (3rd ed.). St. Louis: Mosby/Elsevier.

COMMONLY PRESCRIBED MEDICATIONS

ANTIDEPRESSANTS begin to take effect in three to 10 days, and one-third to one-half the dose necessary for depression is required to manage pain. However, full therapeutic effect may take eight weeks or longer.

Serotonin-norepinephrine reuptake inhibitors

» Venlafaxine hydrochloride (Effexor)

» Duloxetine (Cymbalta)

Selective-serotonin reuptake inhibitors

» Fluoxetine (Prozac, Rapiflux, Sarafem)

» Paroxetine (Paxil)

» Sertraline (Zoloft)

Tricyclic antidepressants

» Amitriptyline hydrochloride (Elavil, Endep)

» Imipramine hydrochloride (Tofranil)

» Doxepin hydrochloride (Sinequan)

» Nortriptyline (Pamelor, Aventyl)

ANTICONVULSANTS

» Gabapentin (Neurontin)

» Carbamazepine (Tegretol)

» Divalproex (Depakote)

» Phenytoin sodium (Dilantin)

» Opiramate (Topamax)

» Pregabin (Lyrica)

ANTISPASMODICS

» Tizanidine (Zanaflex)

» Baclofen (Lioresal)

OPIOIDS

» Oxycodone (OxyIr, Percodone, OxyContin)

» Morphine (MS Contin, Kadian)

» Fentanyl (Duragesic)

» Methadone (Dolophine, Methadose)

TOPICAL

» Lidocaine patch (Lidoderm)

» Capsaicin creams: (Zostrix, Trixaicin, Capsagel)

Source: Barker, E., & Willens, J. S. (2008). Management of the neuroscience patient with pain. Neuroscience nursing: A spectrum of care. (3rd ed.). St. Louis: Mosby/Elsevier.