Neuropathic Pain Rehabilitation

• Professor, Chief of Department

of Physical Medicine &
Rehabilitation, Marmara
University, Istanbul TURKEY
• Secretary General of
Mediterranean Forum of Physical
Medicine and Rehabilitation
• Interest:
• Algology/Pain rehabilitation
• Clinical Neurophysiology
• Osteoporosis
Gulseren AKYUZ • Cancer rehabilitation

MD • Enjoys : Travel, sudoku

• Contact: gulserena@gmail.com
 What is neuropathic pain?
 Injury or disease of the
nervous system
 No cause and responds
poorly to standard
therapies
 May last indefinitely and
even increase over time
 Can result in severe
disability
 Common types of chronic neuropathic pain-
Peripheral causes
 Acute and chronic inflammatory  Neuropathy of nutrition
demyelinizating deficiency
polyradiculoneuropathy  Painful diabetic neuropathy
 Alcohol induced polynerupathy  Phantom pain of extremity
 Chemoteraphy induced  Postherpetic neuralgia
polynerupathy  Plexopathy after radiation
 Complex regional pain  Radiculopathy (cervical,
thoracal, lumbosacral)
syndrome
 Neuropathy because of toxic
 Entrapment neuropathies exposure
 HIV sensory neuropathy  Trigeminal neuralgia
 İdiopathic sensorial nöropati  Posttraumatic neuralgia
 Tumour infiltration of nerves  Peripheral nerve injury
Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff Cr,
Bennett GJ, et al. Advances in neuropathic pain: diagnosis, mechanisms,
and treatment recommendations. Arch Neurol 2003; 60: 1524-34.
Common types of chronic neuropathic pain-
Central causes

 Compression myelopathy due to spinal stenosis

 HIV myelopathy
 Multiple sclerosis pain
 Pain of Parkinson disease
 Myelopathy after ischemia or radiation
 Pain after stroke
 Pain due to posttraumatic medulla spinalis injury
 Syringomyelia
Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff Cr,
Bennett GJ, et al. Advances in neuropathic pain: diagnosis, mechanisms,
and treatment recommendations. Arch Neurol 2003; 60: 1524-34.
 Characteristics of neuropathic pain
 Allodynia: pain elicited by
a nonnoxious stimulus
(clothing, air movement,
touch)
◦ Mechanical (induced by light
pressure)
◦ Thermal (induced by a
nonpainful cold or warm
stimulus)
 Hyperalgesia: exaggerated
pain response to a mildly
noxious (mechanical or
thermal) stimulus
 Signs & Symptoms

 Burning, tingling and

shock-like sensation
 Intolerable pain even to bed
sheets or socks
 Pain after the cause ends
 Worse at nights
 Vary from mild to severe
 Can be progressive
 The effects of neuropathic pain - I

 Quality of Life
◦ Deterioation of physical
functioning
◦ Limitation of activities of
daily living
◦ Difficulties in the job
 The effects of neuropathic pain - II

 Psychological problems
◦ Sleep disturbances
◦ Anxiety
◦ Depression
◦ Loss of self-esteem
◦ Vicious cycle !
The effects of neuropathic pain - III

 Social Consequences
◦ Marital&Family
relations
◦ Intimacy&Sexual
activity
◦ Social isolation
 The effects of neuropathic pain - IV

 Socioeconomic
Aspects
◦ Healthcare costs
◦ Disability
◦ Lost workdays
 Treatment Plan
 Goals of Management

◦ Achieve diagnosis of pain

◦ Identify underlying causes of neuropathic pain
◦ Indicate comorbid conditions
◦ Evaluate psychosocial factors
◦ Assess functional status (activity levels)
◦ Set goals
◦ Develop targeted treatment plan
◦ Determine when and how to refer to specialist
or multidisciplinary team (pain clinic)
 What is “rehabilitation” ?

 A-goal oriented and time-limited process,

aimed at enabling an impaired person to
reach on optimum
◦ Mental
◦ Physical
◦ Social and
◦ Functional level
 Goals of Rehabilitation

 Fixing the dysfunction

 Decreasing pain and drug usage
 Enhancing the quality of life
 Increasing the activity
 Regaining the self-esteem of patient
Physical Agents and Rehabilitation Techniques

 Pain modulators  Rehabilitation techniques

◦ Low frequency currents ◦ Therapeutic exercises
 TENS  Conditioning
 Stretching/flexibility
 Diadynamic currents
 Strenghtening
◦ High voltage galvanic  ROM exercises
stimulation  Desensitization exercises
◦ Laser ◦ Functional restoration
◦ Deep heat agents ◦ Relaxation therapy
 Ultrasound ◦ Psychotherapy
 Short wave diathermy ◦ Acupuncture
Hot and Cold Therapy

 They are used together

◦ Contrast bath
 Weak types are
preferred
◦ Whirlpool
◦ Fluidotherapy
 Low frequency eletrical currents

 TENS
 Diadynamic currents

◦ Jim et al concluded that

TENS may be an effective
and safe therapy in the
treatment of
symptomatic DP
Jin DM, Xu Y, Geng DF, Yan TB. Effect of transcutaneous electrical nerve stimulation on
symptomatic diabetic peripheral neuropathy: A meta-analysis of randomized controlled trials.
Diabetes Res Clin Pract. 2010 May 24. [Epub ahead of print] PubMed PMID: 20510476.
Deep heat agents

 Ultrasound
 Short wave diathermy
 Laser

 It reduces pain and

inflammation
 It increases joint
mobility

◦ Giuliani et al showed the

efficacy of very low level of
laser therapy in expreimental
models

Giuliani A, Fernandez M, Farinelli M, Baratto L, Capra R, Rovetta G, Monteforte P, Giardino L, Calzà L.

Very low level laser therapy attenuates edema and pain in experimental models. Int J Tissue React.
2004;26(1-2):29-37. PubMed PMID: 15573690.
 Massage

 It is not commonly
recommended

◦ Ownby reported a study

about massage in AIDS
patients with NP; and the
results were not
statistically significant
Ownby KK. Effects of ice massage on neuropathic pain in persons with AIDS. J
Assoc Nurses AIDS Care. 2006 Sep-Oct;17(5):15-22. PubMed PMID: 16979511.
 Therapeutic exercises

◦ Conditioning
◦ Stretching
◦ Strengthening
◦ ROM exercises
◦ Desensitization
exercises
 Therapeutic exercises

ROM Exercises Desensitization exercises

 Exercises in water
 Extended exercises in
water can reduce
edema, inflammation
and peripheral
neuropathic pain in
rodents
◦ Kuphal et al developed a NP
models in rodents by making a
peripheral nerve injury in their
sciatic nerves
◦ 25 days of exercises and
swimming decreased pain
Kuphal KE, Fibuch EE, Taylor BK. Extended swimming exercise reduces inflammatory and
peripheral neuropathic pain in rodents. J Pain. 2007 Dec;8(12):989-97. Epub 2007 Sep 24.
PubMed PMID: 17890162.
 Functional Restoration
Mirror Therapy

 Patient puts his affected hand into

mirror box and keeps the unaffected
side in front of the mirror
 Unaffected hand in front of the mirror
makes simple movements, patient
aims to do same movements with the
hand inside although he knows that
pain will increase (visual feedback)
 Patient uses his imagination for this
 Improvement occurs with repetetive
exercises
 Portable box, simple practice and high
patient compliance increase
preferability of mirror therapy for
rehabilitation programmes McCabe CS, Haigh RC, Halligan PW, Blake
DR. Referred sensations in patients with
complex regional pain syndrome type 1.
Rheumatology 2003b;42:1067–73
 Other therapies

 Certain treatments are coming into prominence :

◦ Relaxation therapy
◦ Psychothepary
◦ Acupuncture
 Relaxation therapy

 A process that focuses on

using a combination of
breathing and muscle
relaxation in order to deal
with stress
 It can be used to help
dealing with neuropathic
pain
Pscychosocial support
 Acupuncture

 Cha et al evaluated
antiallodynic effects of
acupuncture in neuropathic
rats
 They found that acupuncture
is effective in the treatment
of neuropathic pain

Cha MH, Choi JS, Bai SJ, Shim I, Lee HJ, Choi SM, Lee BH. Antiallodynic effects of
acupuncture in neuropathic rats. Yonsei Med J. 2006 Jun 30;47(3):359-66.
PubMed PMID: 16807985; PubMed Central PMCID: PMC2688155.
 TENS
 Acupuncture
 Transcranial magnetic stimulation
 Thermotherapy
 Massage
 Electrotherapy
 Ultrasound
 Others ---------No evidence for efficacy
Fattal C, Kong-A-Siou D, Gilbert C, Ventura M, Albert T. What is the efficacy of
physical therapeutics for treating neuropathic pain in spinal cord injury patients?
Ann Phys Rehabil Med. 2009 Mar;52(2):149-66. Epub 2009 Feb 14. PubMed PMID:
19909705.
 Physical Therapy;
◦ Mirror therapy can be effective
◦ Evidence is not enough for efficacy of TENS (level 4)
◦ Occupational therapy can be influential (level 3)
◦ Physical therapy should be a part of standart therapy (level 4)
◦ No evidence for efficiency of multidiciplinary management (level 4)
 Conclusion
 Patient and family education
 Compliance of patient to treatment
 Physical therapy and rehabilitation are as important as
pharmacotherapy
 Psychosocial support should be kept in mind
 New rehabilitation techniques (e.g. mirror therapy)
will be more successful
gulserena@gmail.com