PERT Program

Tip of the Month: August 2004


NEUROPATHIC PAIN

Neuropathic pain is defined by the International Association for the Study of Pain as “pain initiated or caused by a primary lesion or dysfunction in the nervous system.” It arises as a result of injury to the peripheral or central nervous system. Neuropathic pain syndromes seen commonly are diabetic neuropathy, chemotherapy-induced neuropathy, post-herpetic neuralgia, post stroke pain, and phantom limb pain¹. Neuropathic pain currently affects more than two million Americans, and this number is expected to increase with the aging population. As Americans live longer, many will be survivors of chronic diseases such as cancer, HIV, and diabetes, all with known potential for neuropathic pain.

Neuropathic pain is challenging to assess and treat. Unlike pain that is anticipated and can be prevented (i.e., pain associated with a wound dressing change that is managed by pre-medicating the resident prior to the procedure), neuropathic pain is unpredictable. Many residents are not aware that discomfort associated with neuropathic pain syndromes does not always present as pain per se. Rather than asking if the resident is having pain, ask if they are experiencing any pain or unusual sensations. If you do not get a response, give a menu of the more common descriptors related to neuropathic pain such as electric shock, burning, cold, pricking, tingling and itching.

There are classic signs and symptoms of neuropathic pain. The first of three key symptoms is constant, burning pain that feels as if the affected area is “on fire.” The second major symptom is a fleeting, intense, shock-like, or lancinating pain that feels like the stab of a knife or an electric shock. The third symptom is allodynia, a distorted perception of pain in response to a stimulus that is normally not painful². An example of this abnormal perception of pain is the resident with diabetic neuropathy who cannot tolerate the lightweight bed linens over his feet.

Physical signs of neuropathic pain include an exaggerated response to a stimulus (hyperalgesia) and evidence of autonomic instability, as seen by edema, vasomotor and sweating abnormalities, and local skin, nail, or bone changes. For instance, a resident with hyperalgesia experiences prolonged, intense pain from a single, light pinprick. The pain is out of proportion to the stimulus that provoked it.

A thorough assessment is the most important aspect of managing neuropathic pain. Tools specific for assessing the sensations associated with neuropathic pain are available³.

The following neuropathic pain assessment questions help define the type of pain the resident is experiencing and guide pharmacologic strategies4.
  • Are you experiencing any pain or abnormal sensations in your body? Where are you experiencing this (these) sensation(s)? It is important to note where the pain or sensation is located and has it changed over time.

  • How intense is the pain/sensation? On a scale of 0–10, with 0 being no pain/sensation and 10 being the worst pain/sensation, what number do you give the pain/sensation?

  • How unpleasant is the pain/sensation? Using a scale of 0–10 again, with 0 being not unpleasant and 10 being intolerable. Remind residents that pain can have a low intensity and be very unpleasant or have a high intensity and be tolerable.

  • Is this pain/sensation disabling? What can you not do now because of the pain/sensation that you would like to do? Does it interfere with your daytime activities or your sleep? How much time do you spend in bed or reclining? Is it affecting your mood?

  • What makes the pain/sensation better or worse? What are the aggravating and alleviating factors (i.e., cold, heat).

  • In the area of the pain/sensation do you have any swelling, skin color changes, abnormal sweating or dryness of the skin? These changes may indicate the autonomic instability seen in neuropathic pain.


Once a good assessment is complete, appropriate pharmacologic and non-pharmacologic therapy can be determined. Next month’s tip will discuss management of neuropathic pain.


This month’s tip provided by Polly Mazanec, MSN, APRN, BC, AOCN, Palliative Care Consultant, University Hospitals of Cleveland, Ireland Cancer Center and Elizabeth Ford Pitorak, MSN, APRN, CHPN, Director of the Hospice Institute, Hospice of the Western Reserve, Cleveland, OH.


References


  1. Dworkin, R. An overview of neuropathic pain: Syndromes, symptoms, signs, and several mechanisms. The Clinical Journal of Pain. 2002; 18(6):343-349.
  2. Moulin, D. Neuropathic cancer pain: Syndromes and clinical considerations. In E. Bruera & R. Portenoy (eds.) Topics in Palliative Care, Vol 2. Oxford University Press: New York, 1998.
  3. Krause, Steven & Backonja, Misha-Miroslav. Development of a neuropathic pain questionnaire. The Clinical Journal of Pain. 2003; 19(5):306-314.
  4. Galer, B. & Dworkin, R. A Clinical Guide to Neuropathic Pain. McGraw- Hill: Minneapolis, 2000.