myalgias, arthralgias, neuralgias shawn jorgensen, md albany medical center aapm&r annual...

Myalgias, Arthralgias, NeuralgiasShawn Jorgensen, MDAlbany Medical CenterAAPM&R Annual AssemblyOctober 2015

DisclosuresNo financial disclosures

NeuralgiasNeuropathic pain

◦Estimated 4-8% prevalence (Moulin 2014)

◦Diabetics – 16% with painful neuropathy (Bril 2011)

◦Sources Central nervous system Peripheral nervous system

Focal peripheral mononeuropathies Radiculopathies Plexopathies Generalized peripheral neuropathies

Peripheral Neuropathic Pain Disorders of sensation associated with peripheral

neuropathy - definitions◦ Neuropathic pain

“Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.” (Treede 2008)

◦ Peripheral neuropathic pain Only the peripheral portion of the somatosensory system (e.g.

not central poststroke pain)

◦ Dysethsesia An unpleasant abnormal sensation, whether spontaneous or

evoked. (IASP 1994)

◦ Hyperalgesia Increased pain from a stimulus that normally provokes pain.

(IASP 1994)

◦ Allodynia Pain due to a stimulus that does not normally provoke pain.

(IASP 1994)

Peripheral Neuropathic Pain

Neuropathies◦Breaking down neuropathies - Axes

Time of onset Fiber size Modality (sensory, motor, autonomic) Neuron / myelin Aspect of neuron (soma, axon) Length-dependence


Fiber Size◦Small fiber

Symptoms Pain, burning (dysesthesia)

Physical exam: Normal strength Normal vibration, proprioception, light touch Abnormal pinprick, temperature, crude touch Normal reflexes

NCS Normal


Fiber Size◦Large

Symmptoms Tingling (parasthesia)

Physical exam Possibly decreased strength Decreased vibration, proprioception, light touch Normal pinprick, temperature, crude touch Diminished reflexes

NCS Abnormal NCS


Length-dependence◦Length-depenent (distal symmetrical)

Most neuropathies

◦Non-length dependent Multifocal neuropathies

Mononeuropathy mutliplex Lewis-Sumner syndrome HNPP

Autoimmune demyelinating CIDP, AIDP

Ganglionopathy/neuronopathy

Stockingandglovedistribution


Other problems resulting from peripheral neuropathy◦Loss of protective sensation◦Ataxia◦Weakness◦Autonomic dysfunction


Other jobs of physician treating patients with peripheral neuropathy◦Manage acute illness if severe◦Give disease-modifying treatment (when

possible)◦Make sure it is not evidence of something

medically important◦Prevent injury

Charcot joint Diabetic foot care/monitoring

◦Manage ataxia◦Manage weakness


Other jobs of physician treating patients with Peripheral neuropathy◦Work up for underlying cause

AAPM&R, AANEM, AAN (England 2010) Highest yield

Fasting glucose, B12, methylmalonic acid +/- homocysteine, SPEP (level C evidence)

If fasting glucose normal, 2 hour GTT Modifications?

Change SPEP to serum immunofixation (SIFE) – more sensitive (Katzmann 2006)

Add HbA1c

Peripheral Neuropathic PainTreatment

◦Considerations – it’s all about adverse effects Severity – does it require treatment? Oral or topical?

Does the distribution of symptoms make topical treatment practical?

If oral meds, which class is best for this patient?


◦Which oral meds are best? Adverse events

Determine eligibility for classes of antineuropathic pain medications

Caution with antidepressant class Duloxetine

Caution with TCA, triptans (seratonin syndrome) Relatively contraindicated in patients with liver

disease, heavy alcohol use, glaucoma (PDR.net 2015)

Tricyclic antidepressants Caution in patients with increased intraocular

pressure, cardiac conditions, urinary retention, siezures (PDR.net 2015)


◦Which meds are best? Adverse events

Determine eligibility for classes of antineuropathic pain medications Caution with anti-epileptic class

Other sedating medications Operating machinery, students, truck

drivers, pilots (PDR.net 2015)


◦Which meds are best? Efficacy


AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)

◦Level A Pregabalin


AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)◦ Level B

Venlafaxine Duloxetine Amitryptiline Gabapentin Valproate Dextramethorphan Morphine sulfate Tramadol Oxycodone controlled-release Capsaicin Isosorbide dinitrate spray Percutaneous electrical nerve stimulation



◦Level C Lidoderm patch



◦Level U Topiramate Desipramine Imipramine Fluoxetine Vitamins Alpha-lipoic acid


AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)◦Should not be used (Level B)

Oxcarbazepine Lamotrigine Lacosamide Clonidine Pentoxifylline Mexilitine Electromagnetic field treatment Reiki Low-intensity laser treatment

Peripheral Neuropathic PainConsensus statement from

Canadian Pain Society (Moulin 2014)◦General

Reviewed randomized controlled trials, systematic reviews and existing guidelines

Primary goal is to make pain bearable, not gone – keep reasonable expectations


Canadian Pain Society (Moulin 2014)◦Numbers needed to treat (NNT) for

neuropathies TCA 2.1 Opioids 2.6 Cannabinoids 3.4 Pregabalin 4.5 Tramadol 4.9 Duloxetine 5.1 Capsaicin 0.04% 6.2 Gabapentin 6.5 SSRI 6.8


Canadian Pain Society (Moulin 2014)◦Algorithm

1st line – Gabpentoids, TCA, SNRI 2nd line – tramadol, opioids 3rd line – cannabinoids 4th line – topical lidocaine, methadone,

lamotrigine, lacosamide, tapentadol, botulinum toxin


Canadian Pain Society (Moulin 2014)◦Other considerations

TCA adverse effects – drowsiness, dry mouth, constipation,

urinary retention – caution with elderly Nortryptiline and desipramine better tolerated then

amitrpytiline and imipramine Gabapentoids

Few drug interactions Opioids

Tolerance develops to some side effects but not constipation

Peripheral Neuropathic PainIASP (Finnnerup 2015)

◦Meta-analysis of randomized, double blind studies

◦General principles No evidence of efficacy of specific

medications to specific disorders (possible exception of trigeminal neuralgia)

HIV related neuropathy and radiculopathy may be more refractory than other types of neuropathic pain

Peripheral Neuropathic PainIASP (Finnnerup 2015)

◦NNT (number needed to treat) 50% reduction in pain intensity

NNT NNH Botulinum toxin A 1.9 Tricyclics 3.6 13.4 Tramadol 4.7 12.6 Gabapentin 7.2 (“good”) SNRI 6.4 11.8 Pregabalin 7.7 13.9 Strong opioids 10.6 11.7 Capsaicin 8% 10.6

Peripheral Neuropathic PainIASP (Finnerup 2015)

◦First line Gabapentin (including extended release or encarbil) Pregabalin Duloxetine Venlafaxine XR Tricyclics (caution at high doses)

◦Second line Capsaicin 8% patches Lidocaine patches (low effect size) Tramadol (lower tolerability) Botulinum toxin A SQ (weak evidence) Strong opioids (safety concerns)


◦ Inconclusive recommendations – discrepant findings Combination therapy Capsaicin cream Carbemazapine Topical clonidine Lacosamide Lamotrigine NMDA antagonists Oxcarbazepine SSRI Tapentadol Topiramate Zonisamide


◦Recommendations against use Because of generally negative trials or

safety concerns Weak recommendations against

Cannabinoids Valproate

Strong recommendations against Levetiracetam Mexilitine

Peripheral Neuropathic PainSummary

◦Neuropathic pain is common in neuropathies

◦Pain is one of many aspects of a neuropathy that have to be addressed

◦Consider side effects first when treating neuropathic pain

Peripheral Neuropathic PainThank you!!

Peripheral Neuropathic PainBibliography Bril V, England J, Franklin GM, Backonja M, et al: American Academy of Neurology; American

Association of Neuromuscular and Electrodiagnostic Medicine; American Academy of Physical Medicine and Rehabilitation. Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabiliation. PM R. 2011 Apr; 3(4): 345-352.

England JD, Gronseth GS, Franklin G, Carter GT, et al. Practice Parameter: Evaluation of distal symmetric polyneuropathy: Role of laborataory and genetic testing (an evidence-based review): Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology 2009;72:185-192.

Finnerup NB, Attal N, Haroutounian S, McNicol E, et al. Pharmocotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol:2015;162-173.

Katzmann JA, Dispenzieri A, Kyle RA, Snyder MR, et al. Elimination of the need for urine studies in the screening algorithh for monoclonal gammopathies by using serum immunofixation and free light chain assays. Mayo Clin Proc 2006;81:1575-1578.

Merskey H, Bogduk N. Classification of Chronic Pain. Second edition, IASP Task Force on Taxonomy. “Part III: Pain Terms, A Current List with Definitions and Notes on Usage” pp 209-214. IASP Press, Seattle 1994.

Moulin D, Boulanger A, Clark AJ, Clark H, et al. Pharmocological management of chronic neuropathic pain: revised consensus statement from the Candian Pain Society. . Pain Res Manag. 2014 Nov-Dec;19(6):328-335.

"PDR Search." PDR.Net. 2015. Web. 4 Sept. 2015. Treede RD, Jensen TS, Campbell JN, Cruccu G, et al. Neuropathic pain: Redefinition and a grading

system for clinical and research purposes. Neurology 2008;70: 1630-1635.

myalgias, arthralgias, neuralgias shawn jorgensen, md albany medical center aapm&r annual...

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