Neuropathic pain

Current best practice& innovation

Neuropathic pain  ”…Having had neuropathic pain for nearly

all my life I am not the person I should have liked to have been…It is truly the loneliest place there is, when you are trying to smile through gritted teeth at well meaning people who have absolutely no idea what you are going through. Going off to their busy lives while I and thousands of others go and lie down and miss out on so much living…”

4 types of pain Nociceptive Inflammatory Neuropathic Functional

Nociceptive

Inflammatory

Functional

Neuropathic Neuropathic pain may arise as a consequence of

a lesion or disease affecting the somatosensory system

Neuropathic pain Neuropathic pain is

caused by A lesion or disease in

the somatosensory nervous system

Peripheral nervous system

Central nervous system

Neuropathic pain in neuro

‘Central’ rather than ‘peripheral’. Post-stroke – 8% Multiple Sclerosis- 25%, Spinal Injury – 40-50% Traumatic Brain Injury

PrevalenceGeneral population studies, using validated screening instruments, have found that 7–8% of adults currently have chronic pain with neuropathic characteristics.

Described as Burning Electric shocks Shooting Sharp Tingling Buzzing Stabbing Pins &

needles ‘Sunburn’

Positive sensory symptoms Spontaneous pain – no evident stimulus Allodynia – stimulus not normally painful Hyperalgesia – increased response to painful

stimuli Dyasthesia – unpleasant abnormal sensation Parasthesia – abnormal sensation – buzzing,

tingling

Negative sensory symptoms Hypoasthesia – diminished sensitivity to touch &

pain Anasthesia – total loss of sensation Hypoalgesia – diminished pain with painful stimuli Analgesia – absence of pain in response to painful

stimuli

Mechanisms

IASP Factsheet – Mechanisms of Neuropathic pain

Impact ‘Central neuropathic pain is associated with

emotional distress and lower health-related quality of life and affects rehabilitation, mood, sleep, and social functioning’. – IASP 2014

Treatments

Pharmacological

Oral, topical

Injection Surgical – TGN,discectomy

Neuromodulation

SCS, PNS, MCS,deep brain

Intrathecal drug delivery

Psychological therapies

Electrotherapies

acupuncture

PhysicalTherapies

Firstline pharma (NICE) • Pregabalin:up to 600mg• Gabapentin: up to

3,600mgAnticonvulsan

ts

• Amitryptilline – 10 – 150mg

• Duloxetine – 60mgAntidepressan

ts

• Localised pain, & cannot tolerate/wish to avoid drugs

Topical capsaicin

TGN & second-line Firstline for trigeminal neuralgia – carbamazepine

Tramadol as short term rescue therapy

Lidocaine patches for hyperalgia/allodynia

Less sedating antidepressants – nortryptilline, imipramine

Combination therapy

Other pharmaClomipramine, Dosulepin (dothiepin) Doxepin, Lofepramine, TrimipramineCitalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline, Mirtazapine, ReboxetineTrazodone, Venlafaxine, Lacosamide, LamotrigineLevetiracetam, Oxcarbazepine, PhenytoinValproate, Topiramate, BuprenorphineCo-codamol, Co-dydramol, DihydrocodeineFentanyl, Morphine, Oxycodone, Oxycodone with naloxoneTapentadol, Cannabis sativa extract, Flecainide5-HT1-receptor agonists

1st line mode of action Gabapentin &

Pregabalin – voltage gated calcium channel blockers

Amitryptiline – SNRI, & sodium, calcium and voltage gated potassium channel blocker

Synapse

Action potential & ion channels

Neuronal Ion channels

Sensation All sensation takes place by nerve transmission Nerve transmission relies on action potentials

Nerve transmission Resting potential… all gates closed.Cell negative charge 1) chemical gated channels open, allow sodium Na+

in…charge rises inside cell… 2) voltage gated channels open, allow sodium in, rises… 3) Cell depolarises – action potential – wave travels

down axon..+ charged potassium rushes out… 4) at synapse, + = voltage gated calcium channels open 5) Stimulates release of neurotransmitters = Action, movement, feeling, thought, pain Cell repolarises

…

Side effects

Anticonvulsants: somnolence, weight gain, dizziness, peripheral oedema, headache, dry mouth, blurred vision, diploplia, dysarthria, abnormal co-ordination, parasthesia

Also:  sexual dysfunction, constipation, vomiting, flatulence, memory impairment, vertigo, increased creatine kinase level, memory impairment, increased risk of depression & suicidal thoughts and behaviours.

Side effects - TCAs

common : dry mouth, constipation, dizziness, blurred vision, urinary retention, drowsiness, palpitations, orthostatic hypertension, sweating.

Also linked to: cognitive disorders, confusion, gait disturbance, falls

Recent research shows causative link to dementia in long term use ( 2 years low dose)

Cumulative Use of Strong Anticholinergics and Incident Dementia A Prospective Cohort StudyShelly L. Gray,et al JAMA Intern Med. Published online January 26, 2015. doi:10.1001/jamainternmed.2014.7663

Non-pharmacological Electrotherapy – TENS

Psychological therapies – CBT Mindfulness Self-hypnosis

Spinal cord stimulation SCS modifies the perception of neuropathic and

ischaemic pain by stimulating the dorsal column of the spinal cord.

Eligibility Effectiveness: evidence for Failed Back Surgery Syndrome

(FBSS) and Chronic Regional Pain Syndrome (CRPS) >18 yrs failed back surgery syndrome complex regional pain syndrome neuropathic pain chronic pain measuring >5/10 on VAS for 6 months + have tried and not responded to conservative treatments stop/reduce excessive medication, pain mg’ment

strategies be able to manage the technical demands of the

equipment. Successful trial demonstrating 50% pain relief

exclude pain that will not benefit from spinal cord stimulation (widespread pain syndromes) anatomical problems eg spinal deformity, extensive spinal

metalwork,scar tissue in the epidural space active infective illness chronic medical condition ( eg MS, COPD) psychiatric illnesses very high or very low BMI use alcohol, prescription drugs, and/or recreational drugs

excessively allergy to nickel or any other components of the

implantable device.

Spinal Cord Stimulation

Effective in 5-7/10 cases

Evidence in Failed back surgery syndrome & CRPS

2010; £14,500 per patient NHS (East Midlands Specialised commissioning group)

Private: 2015; Spire Roding, East London, £23,000

Problem of adaptation/tolerance

Other nerve stimulators

Peripheral nerve stimulation -

Not routinely funded Oxford Radcliffe have 85% success in 75%

reduction Motor cortex stimulation – electrodes on

surface on brain Post-stroke pain Atypical varieties of trigeminal neuralgia

Deep Brain stimulation Deep brain stimulation – ‘DBS involves

stereotactic targeting of specific anatomical sites within the brain (such as the sensory thalamus or periaqueductal grey matter) to modulate the central processing of pain signal

Small risk of death, CVA, infection

Cost £30,00 OIRO

21% failure rate

‘even partial relief of their pain had resulted in significantly improved quality of life.’

IntraThecal Drug delivery

‘Pump’

ITDD The technique of intrathecal drug delivery (ITDD) is

based on the principle that effective analgesia can be achieved by the action of some drugs at the dorsal horn and adequate concentrations cannot be achieved by systemic administration, or only by high systemic doses. Delivery of the drug by the intrathecal route is a means of achieving these enhanced therapeutic effects. The smaller doses needed for intrathecal administration also allow a reduction in side effects compared to systemic administration. -- British Pain Society 2008

2009: NHS £12,771 per patient – East Midlands Specialised Commissioning group

MS Therapy Centre, Bedford

We heard about Dove House case studies

• married, supportive partner and mother, 3 young children

• diagnosed with MS in 2000• 2000-2009: 6 relapses (iv/oral steroids)• tried beta interferon (3 months =

£1872)• Amitriptyline, Gabapentin, Pregabalin, Carbamazepine, • Dantrolene, Tizanidine• Amantidine Dr. Lia van der Plaat, Dove House

Hospice, Hull UK

unacceptable side effects

Dove House Case studies

Dove House

Dove House

Dove House

Dove House

Dove House

Dove house

APS Therapy machines

Action potentials

How does it work? Specific waveform

simulates Action Potentials

Boosting action potentials

Does not block channels ?Restores effective nerve transmission Enhanced removal of waste products Boosts production of ATP = speeds injury repair &

body’s own healing mechanisms Cellular repair and regeneration enhanced Faster wound and injury healing Improved recovery time after exercise Pain relief Better quality of sleep Enhanced energy

Sports injury before, during, 5, & 10 minutes post APS Therapy

Electron Transport Chain

ATP storage and distribution vehicles of energy

adenosine, ribose, and three molecules of phosphate. Energy is released when the phosphate bond is

broken. Function: convert glucose, from food, into energy. more ATP = better function and more energy

Other Neuro-hormonal effects

Melatonin: significantly raised sedative, anxiolytic,local vasodilation & anticoagulation, limitation of tissue damage at sites of inflammation due to the effects on prostaglandins and free oxygen radicals.

 Leukine enkephalin: progressively increased Effective analgesic due to interaction with opioid receptors as well

as inhibition of substance P (the neurotransmitter responsible for pain transmission). • Limitation of tissue damage at sites of inflammation and/or hypoxia. • Increase in pulse rate and systemic blood pressure, associated with peripheral vasodilation, which results in better perfusion at the affected areas. -

Neuro-hormonal Beta-endorphins: significantly decreased Cortisol: unchanged but uninhibited

Neurohormonal Consequences of APS TherapyProf. Dr. J.M.C. Oosthuizen MBCHB; DMEDSCI  University of the Free State;Prof. Dr. E.H. de Wet MBCHB; MMED; MD

Improvement in sleep Growth hormones, cellular repair secreted stages

3 & 4

simulation vs stimulation

TENSAlternating currentForeign pulseGate theory pain reliefEndorphin on ‘tapping’ mode

APS TherapyDirect currentBiological frequenciesStimulating ATP, detox, injury repair Benefits accrue and are more lasting

No accomodation

Research in APS An assessment of APS Therapy on 285 Patients with Chronic Pain in

2002 reported  a mean average VAPS was 6.8 before treatment and 3.3 after treatment in the over 50s, and 6.3 and 2.2 respectively in the under 50s.  Out of the 285 patients,44 (15%) ended with a ‘0’ VAPS and 199 (69%) with a score of 5 or less. (1)

A trial of APS Therapy in patients awaiting or having neurosurgery for intractable spinal pain concluded that the number of patients treated was too low to reach a statistical conclusion, but that the trend was very promising and they recommended that  patients waiting for destructive surgery should first be put on a thorough trial of APS Therapy.(2) 

In a 1999 randomized, patient blinded, placebo-controlled study, on 76 patients with chronic osteoporotic back pain, reported pretreatment baseline VAPS value average of of 57.79, and post- treatment value after the sixth treatment of 9.7 (p= 0,0001); 6 patients maintained benefits 6 months post treatment.(3)

A study in 1999 on APS Therapy compared with TENS in 99 patients with osteoarthritis of the knee did not find a significant difference between the two treatment groups given just 6 treatments over a 2 week period. The authors did note, however, that the APS group showed a significant improvement in measures of knee flexion and swelling, which persisted even 1 month after the last treatment. (4)

References 1) Papendorp DH van. (2002). Assessment of Pain

Relief on 285 patients with chronic pain. Biomedical Research 2002; 26: 249-253.

2) Du Preez, J. Neurosurgical Pain Conditions University of Pretoria 

3) Odendaal & Joubert APS Therapy- a new way of teating chronic backabacke, a pilot study South African Journal of Anaesthesiology and Analgesia.1999; 5 1

4) Berger, P. Matzner, L Study on 99 patients with osteoarthritis (OA) of the knee to investigate the effectiveness of low frequency electrical currents on mobility and pain: Action Potential Simulation therapy (APS) current compared with transcutaneous electrical nerve stimulation (TENS) and placebo.South Africa Journal of Anaesthesiology and Analgesia

Pilot study: 2013 42 people began the course 6 dropped out 1 x Migraine 1 x Vomiting 1 x Discouragement after 2 weeks 1 x Visual disturbance 2 x Ill with pre-existing medical condition

Of 38 people who completed an 8 week course of APS Therapy:

Of 61 pains that the 38 people had:

Of the 50 pains that improved;

‘Improvement’ Counted as 1 whole point on the VAS

Average improvement overall was 4.7 points

12 people reduced or discontinued medication

Could have been more, hadn’t planned

14 Neuropathic pain in feet & legs

Average VAS pre: 6.3 Average post: 2.5

‘Worst pain’ in neuropathic feet & legs

Other neurogenic & nerve pain

Joint pain & injury

Pre – mean 5.1 post mean 2.2. Actual results quite polarised

‘worst pain’ for joint pain/injury

Headaches

The remaining pains were:

2 x muscle fatigue type pain – no result 1 x post pin and plate – no result

1 x psoriasis pain – good result1 x varicose vein pain – good result

Other benefits attributed include:

Increase in energy, reduction in fatigue x 4 Reduction in swollen legs & ankles x 2 Alleviation of life-long insomnia x 2 Cessation of recurrent UTIs x 2 Improvement in circulation & discolouration Reduction of ‘fatty lump’ on hip Disappearance of swollen glands on neck Cessation of ‘fluid on skull’ sensation Reduction in dizziness & improved cognitive

function

Poppy

Poppy ““I’ve not felt like this since I was about 15! For two thirds

of my life, I’ve been in some kind of pain, with lack of energy, not sleeping properly, having to plan essential things that I need to do, and then struggling to get them done, and frequently cancelling appointments because I’ve not been well enough to make them. Now, it’s my fourth week, and I’ve been active every day for the past 2 weeks. For instance, 3 weeks ago, my mum came to visit, and we walked everywhere, and then I had to spend Monday in bed. 2 weeks ago, a friend came to visit, we did the same walking, but the next day I was just up and active at 6/7 am. Now I’m sleeping well at night, and nothing is such an effort any more. I want to bottle it and give it to everyone I know!”

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www.painfreepotential.co.uk01908 799870

miranda@painfreepotential.co.ukBeds & Northants MS Therapy Centrewww.APSTherapy.com is HQ in Holland

Training monthly in Bedford, at your baseor individually using conferencing software

Thankyou very much