26 Neuropathic Pain


Neuropathic pain

Neuropathic caused by a lesion or disease of the somatosensory nervous system. Peripheral and central neuropathic pain are classified here.

Pathophysiology: The Nervous System Becomes Sensitive When it is Exposed to a Pathological Environment

As peripheral nerves pass through the body they may be exposed to mechanical or chemical irritation at different anatomical points. Prolonged compression or fixation of a nerve may result in a reduction of intraneural blood flow. This then triggers the release of pro-inflammatory substances (calcitonin gene-related peptide and substance P) from the nerve. This by product is referred to as neurogenic inflammation and it can disrupt the normal function of nerves even without overt nerve damage, it can also contribute to the initiation and propagation of chronic pain (Barbe et al., 2020Bove et al., 2019; Matsuda et al., 2019). 

Clinical Examination: Clinical Sensory Testing Can Be Used to Assess for Increased Sensitivity of the Nervous System

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)

Physical Examination

Incorporate one or more of the following physical examination tools to determine the likelihood of neuropathic pain and interpret examination results in the context of all clinical exam findings. If there is an irritated peripheral nerve, clinical sensory testing can be used to assess for areas of hypersensitivity. In addition to orthopedic testing this could involve palpation (neural and non-neural structures). If a hypersensitive peripheral nerve has been identified, a treatment plan is then implemented based on patient-specific assessment findings and patient tolerance.

Upper Limb Neurodynamic Tests 

 

1

2

3

4

5

6

ULNT – Median (1)  

Shoulder girdle stabilization

Shoulder abduction

Wrist/finger extension

Forearm supination

Shoulder external rotation

Elbow extension

ULNT – Median (2)  

Shoulder girdle depression

Elbow extension

Shoulder external rotation

Forearm supination

Wrist/finger extension

Shoulder abduction

ULNT – Radial (3)  

Shoulder girdle depression

Elbow extension

Shoulder internal rotation

Forearm pronation

Wrist/finger flexion

Shoulder abduction

ULNT – Ulnar (4)  

Wrist/finger extension

Forearm pronation

Elbow flexion

Shoulder external rotation

Shoulder girdle depression

Shoulder abduction

Lower Limb Neurodynamic Tests 

 

1

2

3

4

5

 

Slump 

Hands behind back

Thoracic flexion

Extend one knee

Dorsiflex foot

Cervical flexion

 

Straight Leg Raise  

Supine position

Raise the leg with the knee extended

If pain radiates when the angle of the leg is between 30 and 70 degrees (positive)

Increased pain on dorsiflexion of the patient’s foot increases sensitivity of the test

 

 

Femoral Nerve Test 

Prone or side lying

Knee flexion

Extension at the hip

 

 

 

Dorsiflexion-Eversion 

Supine

Place foot into full dorsiflexion & eversion

Hold for 5-10 sec.

 

 


Synopsis of Common Peripheral Nerve Complaints

Affected Nerve

Symptoms

Peripheral Nerve Palpation Point

Head, Neck & Upper Limb

Occipital nerve

Pain, numbness or tingling at the base of the occiput

Base of the occiput

Suprascapular nerve

Shoulder pain, weakness in shoulder abduction and external rotation 

Suprascapular notch 

Dorsal scapular nerve

Upper and mid-thoracic pain, stiffness

Medial border of rhomboids

Long thoracic nerve

Pain, numbness or tingling over lateral flank. Winging of the scapula is possible 

In-between scapula and chest wall 

Median nerve

Pain, numbness or tingling in the thumb, index, middle, and ring fingers.

Upper arm, pronator teres and carpal tunnel

Ulnar nerve

Pain, numbness or tingling in ring and little finger

Upper arm, cubital tunnel

Radial nerve

Pain, numbness or tingling over common extensor tendon

Triangle interval, spiral grove, epimysial groove – extensor, snuff box

Back & Hip

Spinal nerve (dorsal cutaneous ramus)

Dysesthesia on the upper back between the vertebra and scapula (T2-T6)

Deep to back muscles

Intercostal nerve

sharp or shooting thoracic pain  

Anterior cutaneous branches of the thoracoabdominal (T7 –11) and subcostal (T12) nerves – lateral border of the rectus muscle 

Cluneal nerve

Pain, numbness or tingling along iliac crest or into gluteus muscles

Superior rim of the iliac crest

Sciatic nerve

Pain, numbness or tingling felt in the buttock, back of the thigh down to the calf, into the toes

Popliteal fossa

Lateral femoral cutaneous nerve

Paresthesia of the lateral upper thigh

Distal to inguinal ligament

Lower Limb

Saphenous nerve

Knee pain or paresthesia medial thigh

Adductor canal

Tibial nerve

Pain, numbness or tingling over medial ankle and arch of the foot

Tarsal tunnel, posterior to the medial malleolus

Medial & Lateral plantar nerve

Sharp or stabbing heel pain 

Deep to plantar muscle – running under the calcaneus 

Peroneal nerve

Pain, numbness or tingling over lateral ankle and dorsum of foot

Over peroneal muscle belly & dorsum of foot 

Sural nerve

Pain, numbness or tingling over entrapment site and lateral calf

Mid-belly of the gastrocnemius, lateral ankle

 


UBC Medicine Neurology Clinical Skills – Motor, Sensory, and Reflex Examination


Treatment Considerations

Education

Provide patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

The responses to neural mobilization are complex and multifactorial – physiological and psychological factors interplay in a complex manner. Systematic reviews have shown that neural mobilization combined with multimodal care can improve symptoms, decrease disability and improve function for patients who suffer from peripheral nerve entrapment (Basson et al., 2017).

The biopsychosocial model provides a practical framework for investigating the complex interplay between manual therapy and clinical outcomes. Based on this, the investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation (Bialosky et al., 2018).

Central Response
Neural mobilization has a modulatory effect on peripheral and central processes via input from large sensory neurons that prevents the spinal cord from amplifying the nociceptive signal. This anti-nociceptive effect of massage therapy can help ease discomfort in patients who suffer from peripheral nerve entrapments.

Peripheral Response
Neural mobilization may also involve specific soft tissue treatment to optimize the ability of mechanical interfaces to glide relative to the neural structure. The application of appropriate shear force and pressure impart a mechanical stimulus that may attenuate tissue levels of fibrosis and TGF-β1 (Bove et al., 2016Bove et al., 2019). Furthermore, passive stretching may help diminish intraneural edema and/or pressure by mobilizing the peripheral nerve as well as associated vascular structures (Boudier-Revéret et al., 2017Gilbert et al., 2015).

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Home-care recommendations such as hydrotherapy, stretching, splinting and home exercises have been shown to be useful for people with neuropathic pain.

Prognosis

In terms of research evidence neural mobilization has been shown to be particularly helpful for common forms of back, neck, leg and foot pain (Basson et al., 2017). An observed favorable outcome may be explained by overlapping mechanisms in the periphery, spinal cord, and brain, including but not limited to affective touch, contextual factors, neurological factors, and mechanical factors.

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for neuropathic pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Apok, V., Gurusinghe, N. T., Mitchell, J. D., & Emsley, H. C. (2011). Dermatomes and dogma. Practical neurology, 11(2), 100–105. https://doi.org/10.1136/jnnp.2011.242222

Barbe, M. F., Hilliard, B. A., Fisher, P. W., White, A. R., Delany, S. P., Iannarone, V. J., Harris, M. Y., Amin, M., Cruz, G. E., & Popoff, S. N. (2020). Blocking substance P signaling reduces musculotendinous and dermal fibrosis and sensorimotor declines in a rat model of overuse injury. Connective tissue research, 61(6), 604–619. https://doi.org/10.1080/03008207.2019.1653289

Bove, G. M., Harris, M. Y., Zhao, H., & Barbe, M. F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the neurological sciences, 361, 168–180. doi:10.1016/j.jns.2015.12.029

Bove, G. M., Delany, S. P., Hobson, L., Cruz, G. E., Harris, M. Y., Amin, M., … Barbe, M. F. (2019). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain, 160(3), 632–644. doi:10.1097/j.pain.0000000000001443

Bove, G. M., & Dilley, A. (2019). A lesson from classic British literature. Lancet (London, England), 393(10178), 1297–1298. doi:10.1016/S0140-6736(18)32533-9

Challoumas, D., Ferro, A., Walker, A., & Brassett, C. (2018). Observations on the inconsistency of dermatome maps and its effect on knowledge and confidence in clinical students. Clinical anatomy (New York, N.Y.), 31(2), 293–300. https://doi.org/10.1002/ca.23031

Cohen, S. P., & Mao, J. (2014). Neuropathic pain: mechanisms and their clinical implications. BMJ (Clinical research ed.), 348, f7656. doi:10.1136/bmj.f7656

Donnelly, C. R., Chen, O., & Ji, R. R. (2020). How Do Sensory Neurons Sense Danger Signals?. Trends in neurosciences, 43(10), 822–838. https://doi.org/10.1016/j.tins.2020.07.008

Downs, M. B., & Laporte, C. (2011). Conflicting dermatome maps: educational and clinical implications. The Journal of orthopaedic and sports physical therapy, 41(6), 427–434. https://doi.org/10.2519/jospt.2011.3506

Finnerup, N. B., Kuner, R., & Jensen, T. S. (2021). Neuropathic Pain: From Mechanisms to Treatment. Physiological reviews, 101(1), 259–301. https://doi.org/10.1152/physrev.00045.2019

Freeman, R., Edwards, R., Baron, R., Bruehl, S., Cruccu, G., Dworkin, R. H., & Haroutounian, S. (2019). AAPT Diagnostic Criteria for Peripheral Neuropathic Pain: Focal and Segmental Disorders. The journal of pain: official journal of the American Pain Society, 20(4), 369–393. https://doi.org/10.1016/j.jpain.2018.10.002

Goodwin, G., Bove, G. M., Dayment, B., & Dilley, A. (2020). Characterizing the Mechanical Properties of Ectopic Axonal Receptive Fields in Inflamed Nerves and Following Axonal Transport Disruption. Neuroscience, 429, 10–22. https://doi.org/10.1016/j.neuroscience.2019.11.042

Govea, R. M., Barbe, M. F., & Bove, G. M. (2017). Group IV nociceptors develop axonal chemical sensitivity during neuritis and following treatment of the sciatic nerve with vinblastine. Journal of neurophysiology, 118(4), 2103–2109. doi:10.1152/jn.00395.2017

Greening, J., Anantharaman, K., Young, R., & Dilley, A. (2018). Evidence for Increased Magnetic Resonance Imaging Signal Intensity and Morphological Changes in the Brachial Plexus and Median Nerves of Patients With Chronic Arm and Neck Pain Following Whiplash Injury. The Journal of orthopaedic and sports physical therapy, 48(7), 523–532. doi:10.2519/jospt.2018.7875

Koulidis, K., Veremis, Y., Anderson, C., Heneghan, N.R. (2019). Diagnostic accuracy of upperlimb neurodynamic tests for the assessment of peripheral neuropathic pain: A systematic review. Musculoskelet Sci Pract. Apr;40:21-33. doi:10.1016/j.msksp.2019.01.001.

Jain, A., Hakim, S., & Woolf, C. J. (2020). Unraveling the Plastic Peripheral Neuroimmune Interactome. Journal of immunology (Baltimore, Md. : 1950), 204(2), 257–263. doi:10.4049/jimmunol.1900818

Ji, R. R., Chamessian, A., & Zhang, Y. Q. (2016). Pain regulation by non-neuronal cells and inflammation. Science (New York, N.Y.), 354(6312), 572–577. doi:10.1126/science.aaf8924

Ji, R. R., Nackley, A., Huh, Y., Terrando, N., & Maixner, W. (2018). Neuroinflammation and Central Sensitization in Chronic and Widespread Pain. Anesthesiology, 129(2), 343–366. doi:10.1097/ALN.0000000000002130

Ji, R. R., Donnelly, C. R., & Nedergaard, M. (2019). Astrocytes in chronic pain and itch. Nature reviews. Neuroscience, 20(11), 667–685. doi:10.1038/s41583-019-0218-1

Ladak, A., Tubbs, R. S., & Spinner, R. J. (2014). Mapping sensory nerve communications between peripheral nerve territories. Clinical anatomy (New York, N.Y.), 27(5), 681–690. https://doi.org/10.1002/ca.22285

Lee, M. W., McPhee, R. W., & Stringer, M. D. (2008). An evidence-based approach to human dermatomes. Clinical anatomy (New York, N.Y.), 21(5), 363–373. https://doi.org/10.1002/ca.20636

Lees, A. J., & Hurwitz, B. (2019). Testing the reflexes. BMJ (Clinical research ed.), 366, l4830. doi:10.1136/bmj.l4830

Matsuda, M., Huh, Y., & Ji, R. R. (2019). Roles of inflammation, neurogenic inflammation, and neuroinflammation in pain. Journal of anesthesia, 33(1), 131–139. doi:10.1007/s00540-018-2579-4

Nee, R. J., Jull, G. A., Vicenzino, B., & Coppieters, M. W. (2012). The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain. The Journal of orthopaedic and sports physical therapy, 42(5), 413–424. doi:10.2519/jospt.2012.3988

Ogle, T., Alexander, K., Miaskowski, C., & Yates, P. (2020). Systematic review of the effectiveness of self-initiated interventions to decrease pain and sensory disturbances associated with peripheral neuropathy. Journal of cancer survivorship: research and practice, 14(4), 444–463. https://doi.org/10.1007/s11764-020-00861-3

Ridehalgh, C., Sandy-Hindmarch, O. P., & Schmid, A. B. (2018). Validity of Clinical Small-Fiber Sensory Testing to Detect Small-Nerve Fiber Degeneration. The Journal of orthopaedic and sports physical therapy, 48(10), 767–774. https://doi.org/10.2519/jospt.2018.8230

Patetta, M. J., Naami, E., Sullivan, B. M., & Gonzalez, M. H. (2020). Nerve Compression Syndromes of the Shoulder. The Journal of hand surgery, S0363-5023(20)30601-8. Advance online publication. https://doi.org/10.1016/j.jhsa.2020.09.022

Plaza-Manzano, G., Ríos-León, M., Martín-Casas, P., Arendt-Nielsen, L., Fernández-de-Las-Peñas, C., & Ortega-Santiago, R. (2019). Widespread Pressure Pain Hypersensitivity in Musculoskeletal and Nerve Trunk Areas as a Sign of Altered Nociceptive Processing in Unilateral Plantar Heel Pain. The journal of pain: official journal of the American Pain Society, 20(1), 60–67. doi:10.1016/j.jpain.2018.08.001

Satkeviciute, I., Goodwin, G., Bove, G. M., & Dilley, A. (2018). Time course of ongoing activity during neuritis and following axonal transport disruption. Journal of neurophysiology, 119(5), 1993–2000. doi:10.1152/jn.00882.2017

Schmid, A. B., Brunner, F., Luomajoki, H., Held, U., Bachmann, L. M., Künzer, S., & Coppieters, M. W. (2009). Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC musculoskeletal disorders, 10, 11. doi:10.1186/1471-2474-10-11

Schmid, A. B., Nee, R. J., & Coppieters, M. W. (2013). Reappraising entrapment neuropathies–mechanisms, diagnosis and management. Manual therapy, 18(6), 449–457. doi:10.1016/j.math.2013.07.006

Schmid, A. B., Hailey, L., & Tampin, B. (2018). Entrapment Neuropathies: Challenging Common Beliefs With Novel Evidence. The Journal of orthopaedic and sports physical therapy, 48(2), 58–62. doi:10.2519/jospt.2018.0603

Schmid, A. B., Fundaun, J., & Tampin, B. (2020). Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain reports, 5(4), e829. https://doi.org/10.1097/PR9.0000000000000829

Scholz, J., Finnerup, N. B., Attal, N., Aziz, Q., Baron, R., Bennett, M. I., Benoliel, R., Cohen, M., Cruccu, G., Davis, K. D., Evers, S., First, M., Giamberardino, M. A., Hansson, P., Kaasa, S., Korwisi, B., Kosek, E., Lavandʼhomme, P., Nicholas, M., Nurmikko, T., … Classification Committee of the Neuropathic Pain Special Interest Group (NeuPSIG) (2019). The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain, 160(1), 53–59. https://doi.org/10.1097/j.pain.0000000000001365

Stonner, M. M., Mackinnon, S. E., & Kaskutas, V. (2020). Predictors of functional outcome after peripheral nerve injury and compression. Journal of hand therapy: official journal of the American Society of Hand Therapists, S0894-1130(20)30039-9. Advance online publication. https://doi.org/10.1016/j.jht.2020.03.008

Wang, Q., Lin, J., Yang, P., Liang, Y., Lu, D., Wang, K., Gan, W., Fu, J., Gan, Z., Ma, M., Wu, P., He, F., Pang, J., & Tang, H. (2020). Effect of Massage on the TLR4 Signalling Pathway in Rats with Neuropathic Pain. Pain research & management, 2020, 8309745. https://doi.org/10.1155/2020/8309745

Zhu, G. C., Böttger, K., Slater, H., Cook, C., Farrell, S. F., Hailey, L., … Schmid, A. B. (2019). Concurrent validity of a low-cost and time-efficient clinical sensory test battery to evaluate somatosensory dysfunction. European journal of pain (London, England)23(10), 1826–1838. doi:10.1002/ejp.1456

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