he root causes of neuropathic pain put it in a different category to more familiar types

of pain, which may in part account for the relatively poor performance of clinicians in
diagnosing and treating the condition. It stems from an abnormal activation of the
body’s pain response, a disturbance of function or pathological change in a nerve.

This can be the result of dysfunction or injury to the nervous system – to a specific
nerve, the spinal cord or the brain itself. Evidence to date suggests that this often
manifests itself as ectopic impulse formation, hyper-excitability and loss of inhibitory
control.

Common causes of neuropathy include accidents, surgical procedures or damage to

the nerve structure from infections such as shingles, or through long-term conditions
such as diabetes. Damage to the peripheral nerve system can also be caused by
pressure on the nerve from a malignant tumour or, more commonly, from spinal
abnormalities.

In many cases, damaged nerves can heal without resulting in ongoing pain, but in
some cases, despite complete healing to the surrounding tissue, nerves can become
excitable, firing off pain impulses from the site of the nerve damage. Essentially, the
brain is being tricked into thinking that pain impulses are coming from pain receptors
in the skin or organs.

In patients suffering neuropathic pain, three types of observable changes can occur:
painful symptoms, visible skin changes and loss of sensation. Essentially, these
patients’ pain systems bombard the spinal cord and brain with unusual patterns of
impulses, often producing bizarre sensations – both painful and not – which can be
vital clues for clinicians in diagnosing neuropathic pain.

Spontaneous experience of pain, which seemingly has no cause, or "evoked" pain,

where an ordinary physical stimulus produces an unusual or exaggerated sensation of
pain, are further indications that neuropathy may be the cause. Some spontaneous pain
is continuous. In other cases, it manifests as paroxysmal pain, characterised by
intermittent sensations that occur without stimulus.

Evoked pain can come from contact or circumstance that would normally go
unnoticed, such as brushing clothes against the skin or a change in temperature. It can
also include the sensation of pain in a different part of the body to that which is
receiving the stimulus, or the radiation of pain from a specific area to a wider region.

FOUNDATIONS FOR DIAGNOSIS

Given the obvious factors that might indicate neuropathy, it may be surprising that up
to two-thirds of GPs have difficulty recognising neuropathic pain. Many specialists,
including endocrinologists treating diabetes and even pain specialists, also report
problems in diagnosing the condition.

A clinical diagnosis of neuropathic pain should only be made when the distribution of
pain and the associated sensory abnormalities, jointly and in a clinical context, point
to a neurological condition. Put simply, neuropathic pain is pain that often occurs in
an area of abnormal or absent sensation.
Patients with neuropathic pain usually complain of spontaneous pain, such as the
continuous sensation largely felt in cutaneous or deep tissues and, on occasion, from
viscera, or of paroxysmal and evoked pain. However, the demonstration of nerve
dysfunction is crucial corroborating evidence in the diagnosis of neuropathic pain.

Clinicians diagnose neuropathic pain on the basis of a combination of symptoms and

examination evidence that suggests nerve dysfunction. Given that pain is a subjective
phenomenon and that traditional tests, such as vibrametry and nerve conduction
studies, have only measured function in large myelinated fibres, basing a diagnosis on
examination evidence can be quite a challenge.

"Pain systems bombard the spinal cord and brain with unusual patterns of impulses,
often producing bizarre sensations – both painful and not – which can be vital clues
for clinicians in diagnosing neuropathic pain."

In some cases, special nerve testing is performed to detect nerve damage, as is

common in response to reports of pain from changes in temperature. These tests may
well highlight nerve damage, but cannot in themselves prove or disprove that a patient
is suffering with pain caused by that nerve damage.

It is fortunate that the diagnosis of neuropathic pain is now receiving much more
attention from researchers. This has resulted in the development of pain scales that
can help doctors detect whether neuropathic pain might be the cause of their patient’s
pain. Recently, neurophysiological tests have been developed. These enable clinical
assessment of the peripheral and central systems for sensing pain.

Alternative approaches have focused on the development of standardised assessment

tools based on the symptoms reported by patients. Lists of symptoms that can be
described verbally are often used to identify specific neuropathic pain descriptors.
One problem, however, is that presently these lists have not been successfully tested
for their ability to allow clinicians to discriminate between neuropathic and other
kinds of pain.

Nevertheless, these verbal descriptors can be useful, as they allow clinicians to rate a
patient on the neuropathic pain scale (NPS). This consists of ten verbal descriptions,
each rated on an 11-point numerical rating scale. The process was developed from
clinical experience and used single descriptors to discriminate between four
diagnostic categories of neuropathic pain.

Only post-herpetic neuralgia could be distinguished from the other diagnostic groups,
such as reflex sympathetic dystrophy, diabetic neuropathy and peripheral nerve injury.
The NPS was not used to discriminate between neuropathic pain and pain resulting
from a measurable physiological event.

THE LANSS PAIN SCALE

Clearly, additional assessment techniques were required. The Leeds Assessment of

Neuropathic Symptoms and Signs (LANSS) Pain Scale is comprised of seven
elements, consisting of five symptom items and two examination items. These are
delivered by a clinician in an interview format.
The purpose of this test is to more accurately assess the probability that a patient’s
pain is dominated by neuropathic mechanisms. It is not intended to help clinicians
assess the severity of the pain or its causes. So far, it is the only published tool with
validity when it comes to discriminating between neuropathic and nociceptive pain
irrespective of disease-based diagnostic categories.

The LANSS scale, which is generally perceived as easy to use, is now more widely
available to clinicians and patients. Thanks in part to the Neuropathy Trust, the
LANSS pain scale is available online for patients and professionals alike to view, test
and evaluate. This includes the S-LANSS, or self-report LANSS test, which can be
used by patients without the presence of a clinician.

Both the LANSS and S-LANSS tests result in the patient receiving a score out of 24.
If a patient registers 12 or more on this scale then there is a strong suggestion that
neuropathic pain is present to some degree. The current track record of LANSS tests
has shown that four out of five patients with chronic pain were correctly classified as
suffering from nociceptive or neuropathic pain.

It must be stressed, however, that there is still a small chance that a patient who scores
below 12 on the scale may indeed have some neuropathic pain, and also that a patient
with a score of more than 12 may not. For this reason it is advisable that a patient
undertaking the S-LANSS test should consult a doctor to get a more precise diagnosis
before treatment. With LANSS and S-LANSS easy to complete online through the
Neuropathy Trust website, it is hoped that this will provide a platform on which to
build more detailed histories.

Although a consensus on the classification and assessment of neuropathic pain has yet
to be reached, the development of detailed records will make it easier to assess the
cause of pain and its response to treatment, allowing patients and their doctors to deal
more confidently with neuropathic pain.

Neuropathic pain
On the other hand, neuropathic pain is caused by abnormal activation of the pain
system. This either follows injury to the nerve (e.g. due to surgery or an accident), or
it can be the result of damage to the nerve structure from infection (e.g. shingles) or
other diseases like diabetes. Injured or damaged nerves often repair or heal without
causing pain. Occasionally though, these nerves can become excitable and start to fire
off pain impulses from the site of the nerve damage long after the surrounding tissues
have healed. The brain is tricked into thinking that these impulses are coming from
pain receptors in the skin or organs. This is one reason why people who have had an
amputation can ‘feel’ pain in the missing limb when it is not there: phantom limb
pain.

FEATURES OF NEUROPATHIC PAIN

The underlying abnormal activation of the pain system in neuropathic pain bombards
the spinal cord and brain with odd patterns of pain impulses. This often results in
some bizarre painful and non-painful sensations that can feel very strange and it is
these features that can give a clue to the presence of neuropathic pain. In patients with
neuropathic pain, there are three types of changes that can occur; painful symptoms,
visible skin changes and loss of sensations. These are described in detail here.

Painful symptoms
Classically, neuropathic pain results in ‘spontaneous’ pains, which are painful
sensations that seem to have a life of their own, and ‘evoked pains’ which are bizarre
and painful responses to an ordinary physical stimulus.

Spontaneous pains are of two types. The first is called ‘continuous’ which is like a
steady and ongoing painful sensation often felt in the skin where it might feel like
burning, cutting, pricking, tingling, pins-and-needles and stabbing. Sometimes
continuous pain is felt in the deep tissues where it is commonly described as
cramping, aching, throbbing and crushing.

The second type of spontaneous pain is called ‘paroxysmal’ pain which means that
they are intermittent and often come on out of the blue. Paroxysmal pains are usually
described in terms of shooting, stabbing, lancinating or jabbing.

Evoked pains are usually exaggerated responses to some ordinary everyday physical
event. One example is called ‘allodynia’ (allo-din-eeya), literally ‘different pain’.
This describes pain that comes on from a simple contact that is not normally painful
like brushing clothes against the skin (mechanical allodynia) or a cool breeze (thermal
allodynia, if caused by temperature changes). Other types of abnormalities mean that
physical contact in one area of skin results in painful sensations in another, or pain
that radiates down a whole leg or arm. Some patients will report prolonged painful
after-sensations long after the initial event has passed (called hyperpathia). Patients
with neuropathic pain will often report that their skin just feels hyper-sensitive to
ordinary knocks and cuts: hyperalgesia (hyper-al-jees-eeya).

Skin changes
Visible changes in the skin that overlies a painful area can be a tell-tale sign that
neuropathic pain is present. These changes are complex and not well understood but
give rise to alterations in blood flow resulting in skin that is pinker or redder, or
sometimes more blue, dusky and mottled looking than other areas. Alterations in the
way the skin works and grows can make it look waxy, dry, puffy or swollen. In some
cases, hair and nail growth is affected in the painful area.

Loss of sensations
Naturally, if nerves are damaged the normal sensations that they carry can be lost.
Probably the most common finding is numbness in the painful area as normal feeling
has been lost. Interestingly, the nerves that are the most prone to damage (in other
words, nerves that are the first to stop working in diabetes or old age for example) are
ones that carry temperature sensations. This stops us detecting whether something is
hot or cold and is the basis of a reliable test of early nerve damage.

DIAGNOSIS OF NEUROPATHIC PAIN

Difficulty in recognizing neuropathic pain
Doctors base their diagnosis of neuropathic pain on a combination of the patient’s
symptoms and a clinical examination that points to nerve damage or injury. In some
cases, special nerve testing is done to detect nerve damage (like the example above
for temperature sensations). Although these tests might highlight nerve damage, the
tests themselves cannot prove or disprove that a patient is suffering with pain caused
by the nerve damage. Patients with neuropathic pain often say that they feel that their
doctor, family and friends find it hard to believe their descriptions of their pain. They
become understandably frustrated at the delay this causes in getting the right
treatment for this condition.

Fortunately, the diagnosis of neuropathic pain is receiving more attention by

researchers. This has resulted in the development of pain scales that can help doctors
to detect whether neuropathic pain might be the cause of their patient’s pain. These
scales are generally easy to use and thanks to the Neuropathy Trust, one of these
scales (the LANSS pain scale) is now available on their website for patients and
professionals alike to view and try out. (see below)

The LANSS Pain Scale

The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale has
seven items consisting of five symptom items and two examination items. Usually,
the examination items are done by a doctor but a modified version (the S-LANSS or
self-report LANSS) allows people to do this themselves. The purpose of these scales
is to assess whether the pain that is experienced is predominantly due to nerve damage
or not.

Both the LANSS and S-LANSS are scored out of 24; a score of 12 or more is strongly
suggestive of neuropathic pain. In tests, 4 out of 5 patients with chronic pain were
correctly classified as nociceptive or neuropathic pain by the LANSS. This does mean
however, that there is a small chance that a patient who scores below 12 may still
have neuropathic pain, and that a patient with a score of over 12 may not really have
this condition. For this reason, although the LANSS is a useful guide to the type of
pain, it is best to consult with your doctor to get the exact diagnosis before starting
treatment.

The S-LANSS is now ready for use on the Neuropathy Trust website, and can be
completed online following simple instructions. The website will automatically
calculate the score and provide a print out for future use.

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Alarmingly, nearly sixty per cent of Europeans have never heard of neuropathic pain
(NeP), 1a a debilitating nerve condition that affects approximately 22 million people,
2,3 according to new surveys carried out amongst the general public and patients
across Europe. NeP can often be a complication of diabetes, shingles, HIV and cancer
causing such unbearable pain that individuals are often left unable to walk or even
wear clothes.

In the survey, commissioned by Pfizer and the Neuropathic Pain Network (NPN),
nearly two thirds (58%) had not heard of NeP1a and of those who had heard of it,
over a third (34%) did not understand what it is.1b More respondents said they would
usually buy over-the-counter painkillers in response to any pain than seek diagnosis
from a clinician,1c which is worrying given that NeP is common, under-treated and
under-diagnosed.4

"These findings emphasize the vast lack of knowledge about neuropathic pain and the
importance of educating people about the associated signs and symptoms and how to
seek medical advice," comments Penney Cowan, Vice President of the Neuropathic
Pain Network. "The reality is that there are millions of people with nerve pain in
Europe undiagnosed and not receiving the optimal standard of care. Launching NeP
Day, a culmination of the Can You Feel my Pain? campaign, is one important step on
the road to achieving awareness and understanding of the condition."

The patient survey specifically sheds further light on the lack of awareness and
diagnosis, demonstrating that the majority of patients with NeP (72%) had not heard
of it before they were diagnosed,5a and some can often wait up to 2 years to receive
the diagnosis.5b Approximately 50% of people with NeP felt their pain equated to
'burning oneself',5c which is thought to be the most painful experience by those who
don't suffer from the condition.1d

"It's heartbreaking that the majority of patients in this survey reported that they 'never
feel like a real person',5d commented Harry Kletzko, President of the Neuropathic
Pain Network, "This is truly upsetting at a time when many treatment options exist,
together with strong support networks to help patients live better lives".

Neuropathic Pain: A Debilitating Condition

NeP can have a significant impact on patients' lives leaving many unable to work,
walk or even wear clothes as the contact with their skin can cause an unbearable
burning pain. However, it is a condition that often is under-diagnosed and under-
treated.4 NeP is initiated or caused by a lesion or dysfunction of the central nervous
system (either peripheral or central). Many patients experience NeP as a complication
from diabetes, shingles, HIV, cancer, multiple sclerosis, stroke or spinal cord injury.
To non-sufferers lying on a bed of nails sounds painful, but some people with NeP
feel like they are doing this everyday, very often describing the pain as feeling like
'burning', 'shooting', 'stabbing' or 'electric shock-like' sensations. In recent years a
number of screening tools have been developed to help physicians identify this
difficult to diagnose condition.

The 'Can You Feel My Pain' European Awareness Campaign

The survey was conducted by Pfizer in collaboration with the Neuropathic Pain
Network to identify gaps in the knowledge around the disease between sufferers and
general public across Europe. The results have since been used to raise awareness of
neuropathic pain amongst consumers at the launch of the 'Can You Feel My Pain'
European campaign events in Scotland (August 19), The Netherlands (September 28),
Sweden (October 3) and Germany (October 10). The campaign saw a team of
renowned 3D street artists create images on cities streets, to depict the experiences of
a person with neuropathic pain. The campaign culminates today on October 13 which
sees the launch of the first Neuropathic Pain Day across Europe.

About the Survey

In July 2008, Neuropathic Pain Network and Pfizer commissioned GfK to conduct a
multi-country survey of people with NeP and the general public. A survey of 824
individuals and 150 patients was conducted in four European countries including: the
United Kingdom, Germany, the Netherlands and Sweden. Fieldwork was conducted
from July 2008 through to September 2008.

http://www.medicalnewstoday.com/articles/125270.php

Pain, both acute and chronic, affects millions of people in the United States. Pain
can be categorized along a variety of dimensions, including one of the most important
divisions, nociceptive versus neuropathic pain (NP). Nociceptive pain results from
activity in neural pathways secondary to actual tissue damage or potentially tissue-
damaging stimuli. NP is chronic pain that is initiated by nervous system lesions or
dysfunction and can be maintained by a number of different mechanisms. Three
common conditions that are often associated with acute and chronic NP are painful
diabetic peripheral neuropathy (DPN), painful postherpetic neuralgia (PHN), and
cancer. Although estimates of DPN vary widely depending on the assessment criteria
employed, as many as 50% of people with diabetes have some degree of DPN. PHN
develops secondary to herpes zoster infection, and there are 600 000 to 800 000
cases of herpes zoster in the United States each year, with 9% to 24% of patients
progressing to PHN. Acute or chronic NP may occur in more than 50% of patients
with cancer pain. Patients with painful DPN, PHN, or cancer may present with a
variety of acute or chronic NP symptoms, and it is important to distinguish these
conditions from other pain syndromes so that appropriate therapy can be initiated.

(Am J Manag Care. 2006;12:S256-S262)

http://www.americanjournalofmanagedcare.com/ArticleAbstractOnly.cfm?
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