P - NEUROPATHIC PAIN Tools & Resources

Diagnosis of neuropathic pain, including its causes, should be informed by:

1. a complete patient history
2. a physical examination
3. the International Spinal Cord Injury Pain (ISCIP) Classification system
4. investigations.

A complete patient history should focus on determining the nature of pain symptoms that could indicate potentially reversible causes, aggravators and/or mimics of neuropathic pain, and the consequences of pain on function and quality of life. Essential elements of a complete patient history are the following:

1. Nature of pain: onset or triggering event, position or location, quality (for example, burning, electric shock-like), radiation, severity, timing (for example, constant or intermittent, spontaneous, or evoked) and aggravating or alleviating factors
2. Changes in neurologic status: changes in strength, sensation, or spasticity
3. Associated symptoms: ask about red flag signs and symptoms such as vasomotor instability (Red flags are serious underlying conditions that may cause, aggravate or mimic NP. Red flag indicators are symptoms and signs that suggest that a particular condition may be present. It is essential to identify red flags, as effective treatment could significantly improve or eliminate NP if managed appropriately and if left untreated may have serious adverse consequences for the patient).
4. Screening for interference: interference with sleep, physical function and mood or emotional function
5. Recent changes in health: new medical diagnoses such as diabetes and other conditions predisposing to polyneuropathy
6. Additional historical components: based on presentation and suspected etiology.

The physical examination should include, at a minimum, neurologic, skin, and musculoskeletal examinations. Additional systems should be examined based on symptoms. Essential elements of the physical examination are the following:

1. Vital signs
2. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)
3. Reflexes, tone
4. Range of motion assessment of extremities, joint swelling or redness
5. Visual inspection of the skin for integrity
6. Calf measurement to assess for deep vein thrombosis
7. ISNCSCI autonomic standards.

Additional physical examination components may be included based on presentation, for example:

1. Primary abdominal region pain: abdominal screening examination
2. Respiratory involvement: chest assessment
3. Autonomic symptoms: assessment for etiology of autonomic dysreflexia (noxious stimuli).

Determining a specific etiology can be difficult and may require additional investigations. The selection of these investigations is geared towards the diagnoses of greatest clinical likelihood, and diagnostic tests are based on the presentation. It is essential to image the appropriate area of the spinal cord for all patients with any change in neurologic status, such as changes in neurologic level, tone, and reflexes. If any suspicion of urinary tract infection exists, it is important to perform a urinalysis and culture and sensitivity. Patients with primary abdominal region pain should have an abdominal ultrasound, radiography, or computed tomography as necessary to determine the source of the pain; blood work may include lipase, amylase, liver enzymes and kidney function tests. Signs and symptoms suggesting respiratory involvement could lead to further investigations such as chest assessment or radiography. In patients in whom pulmonary embolism is suspected, a computed tomography angiogram or ventilation/perfusion lung scan should be performed. Other investigations should be performed based on the differential diagnosis, as appropriate.

Assess for serious underlying conditions (red flags) that may cause, aggravate, or mimic neuropathic pain and that require further investigation and prompt medical review. (CANPAIN DIAG 2016, p.S10; Level C)

Red flags are serious underlying conditions that may cause, aggravate, or mimic neuropathic pain. Red flag indicators are symptoms and signs that suggest that a particular condition may be present. It is essential to identify red flags, as effective treatment could significantly improve or eliminate neuropathic pain if managed appropriately and, if left untreated, may have serious adverse consequences for the patient.

Red flag table: https://www.nature.com/articles/sc201689/tables/1

Assess and manage psychosocial factors (yellow flags) that may contribute to pain-related distress and disability. (CANPAIN DIAG 2016, p.S10; Level C)

Addressing psychosocial factors (yellow flag conditions) is essential for treatment success in an individual who has pain after SCI. Yellow flags can complicate and exacerbate the presentation of neuropathic pain and may contribute to pain-related distress and disability. Examples of yellow flag conditions or factors include the following:

1. Depressive symptoms
2. Altered appetite
3. Poor motivation to complete daily activities or work because of pain
4. Decreased participation in valued activities
5. Pre-existing pain problems with evidence of poor adjustment
6. Avoidance of activities associated with pain
7. Extensive periods of rest or bed rest
8. Evidence of catastrophic thinking, preoccupation with pain prognosis, significant anxiety, and panic symptoms
9. Use and dependence on alcohol or illicit substances
10. Increasing opioid dependence or misuse
11. Disruption of sleep quality and/or duration
12. Lack of support from family members towards pain and activity.

Address patient concerns, expectations and needs as part of the neuropathic pain assessment. (CANPAIN DIAG 2016, p.S11; Level C)

It is vital to remember that pain is subjective, and individuals differ in their expectations of treatment and needs with regards to pain. As a result, it is important to develop rehabilitation goals and the treatment plan in partnership with the patient. Goals of treatment, such as improvement in function, reduction in pain severity and improvement in mood, should be reviewed before initiating a particular treatment. Consider using SMART (Specific, Measurable, Agreed upon, Realistic and Time-based) goal methodology when setting treatment goals. Establishing specific treatment targets also allows evaluation of treatment benefits.

Standardized evaluation of treatment response should be carried out by the healthcare team at regular intervals. (CANPAIN DIAG 2016, p.S11; Level C)

Monitoring a patient’s response to treatment, including efficacy, tolerance, dose-escalation, and side effects, is vital to modifying any suboptimal treatments. Such modification should be performed as rapidly as feasible. Adverse events need to be balanced against treatment benefits when determining whether to continue treatment, and discussion with the patient should inform decision-making.

Comparing treatment targets with achieved outcomes helps determine whether continued use of a treatment is worthwhile. It is also important to assess domains of intensity, mood, and function when determining treatment success. In addition to the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS v2.0), supplementary standardized measures such as the opioid risk tool may be used to evaluate outcomes not contained in the data set. As some medications to treat neuropathic pain, such as opioids, are subject to misuse, it is important to monitor for aberrant behaviour, as this may indicate either misuse or inadequate pain control. The National Opioid Use Guideline Group provides additional recommendations for opioid use.

The evaluation of treatment response should include assessment of changes in pain intensity, mood and function using the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) v2.0. Evaluation also includes an assessment of adverse events, aberrant behaviour, and compliance. (CANPAIN DIAG 2016, p.S11; Level C)

Monitoring a patient’s response to treatment, including efficacy, tolerance, dose-escalation, and side effects, is vital to modifying any suboptimal treatments. Such modification should be performed as rapidly as feasible. Adverse events need to be balanced against treatment benefits when determining whether to continue treatment, and discussion with the patient should inform decision-making.

Comparing treatment targets with achieved outcomes helps determine whether continued use of a treatment is worthwhile. It is also important to assess domains of intensity, mood and function when determining treatment success. In addition to the ISCIPBDS v2.0, supplementary standardized measures, such as the opioid risk tool, may be used to evaluate outcomes not contained in the data set. As some medications to treat neuropathic pain are subject to misuse, such as opioids, it is important to monitor for aberrant behaviour, as this may indicate either misuse or inadequate pain control. The National Opioid Use Guideline Group provides additional recommendations for opioid use.

International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) v2.0: https://www.iscos.org.uk/uploads/sitefiles/Data%20Sets/Papers%20from%20Spinal%20Cord%20-Data%20Sets/ISCIBDS_Pain_2.pdf

All patients with new-onset or worsening pain need to be reassessed. (CANPAIN DIAG 2016, p.S11; Level C)

It is critical to pay particular attention to late-onset pain or sudden worsening of chronic pain. New-onset or worsening chronic neuropathic pain may require exclusion of treatable causes of the pain, assessment for new-onset red flag or yellow flag conditions and a full neuropathic pain assessment.

Delivery of care for neuropathic pain in individuals with SCI should be:

1. coordinated
2. interprofessional
3. timely
4. patient-centred
5. using a biopsychosocial framework
6. evidence-based.

Numerous factors affect the presentation of chronic pain, including psychosocial and environmental factors. Conversely, chronic pain can significantly affect function, mood, and social relationships. Therefore, management of chronic pain after SCI in patients with complex presentations requires an interprofessional or interdisciplinary team approach that incorporates medical, physical, educational and cognitive-behavioural components. Communication between healthcare providers, between healthcare providers and administrators, and between healthcare providers and the patient is a central tenet of coordination of care services.

A biopsychosocial framework should guide the structure of a program and individual care plans. This model considers the interplay between physiology, psychology and social factors on the pain experience that affects neuropathic pain outcomes for individuals with SCI.

As proposed by Strauss et al., evidence-based decisions are essential to advancing practice, with priority given to SCI-specific guidelines and studies.

An individual with SCI and either:

1. new-onset or worsening spinal cord injury-related neuropathic pain, and/or,
2. ongoing pain that is difficult to manage and/or,
3. dissatisfaction with their current pain management protocol,

should be screened and assessed by a clinician with experience in managing individuals with SCI. (SYS CARE 2016, p.S25; Level C)

It is essential to involve clinicians with SCI experience when working with patients who have SCI-related neuropathic pain, who present with any of the conditions outlined in Recommendation V.4.2. A clinician with SCI experience can recommend relevant referrals, assessments, investigations, and treatment steps as appropriate. If necessary, on the basis of the results of the assessment, then this individual can act as a gatekeeper to team-based care for SCI-related neuropathic pain. If a diagnostic workup is required to determine the etiology or triggers of neuropathic pain after SCI, it is essential to involve the rehabilitation medicine specialist to ensure that relevant conditions are considered, and that appropriate investigations are implemented.

Multidisciplinary care coordinated through an SCI rehabilitation team is recommended when significant functional impacts and/or significant psychological comorbidity factors resulting from neuropathic pain need to be addressed. Further, a detailed plan of care shared among healthcare providers needs to be implemented across primary, secondary, and tertiary services. (SYS CARE 2016, p.S25; Level C)

It is important to recognize that pain management strategies should also address the functional and psychological impacts of pain, as current treatments may not eliminate pain or even reduce it effectively. As patients should expect to live with some degree of pain and discomfort, it is essential that they learn to minimize the impact of these symptoms on their daily lives. Generally, delivery of comprehensive care through an SCI rehabilitation team has been shown to be central to improving SCI outcomes. Access to such a team is therefore essential to managing complex functional impacts and/or psychological comorbidity more effectively. Currently, the implementation of specialized treatments may require access to a specialized pain clinic. Open communication and coordination between pain specialists and the SCI specialist team is required. Moving forward, we recommend that, given the unique needs of the SCI population, these treatment options be available at SCI-specific rehabilitation facilities.

As patient needs evolve, team members may change over time. The team approach to patient care can improve access to care, quality of care, and cost-effectiveness. The team approach is effective in increasing diagnostic accuracy and timeliness of treatment, which can improve health outcomes and patient satisfaction while increasing resource utilization efficiency and job satisfaction for clinicians. In addition, the team approach can streamline communication with patients and families. It is also important to consider the role of telemedicine, e-consults, and other forms of distance communication to allow staff from specialized rehabilitation centers to continue to provide oversight when travel is a barrier to optimal care delivery, such as may occur for patients in rural areas.

The multidisciplinary team should develop a detailed and integrated rehabilitation care plan that includes a focus on neuropathic pain in alignment with Accreditation Canada 2014 standards (https://accreditation.ca/spinal-cord-injury-rehabilitation-services). Multidisciplinary care should take a patient-centred, goal-directed, holistic, and functional approach to pain management that incorporates the caregiver and/or significant other in the care plan. Members of the multidisciplinary team should include the various rehabilitation disciplines such as physiatry, physiotherapy, occupational therapy, psychology, social work, nursing, and other professionals as needed.

An individual with neuropathic pain as a result of SCI should be discharged from specialized care when three conditions are met:

1. a stable plateau has been reached in pain severity and/or pain-related functional status
2. an ongoing plan linked to resources and provider follow-up is in place
3. self-management techniques have been taught.

The goal at discharge from specialized care should be stable pain severity and optimized function relative to an individual’s ongoing pain severity. Complete alleviation of pain is not usually a realistic outcome. A stable plateau may be considered to have been reached when the care providers and the patient feel maximal gains have been reached, given the available time and resources, in managing pain and its impact on everyday functioning. Periodic reassessments by specialized care providers may be appropriate after discharge to ensure the stability of pain management.

The goal of self-management education is to equip the patient to manage pain as independently as possible.

The SCI rehabilitation team should engage in continuous quality improvement, including evaluation and feedback efforts regarding their pain management practices based on patient outcomes. The plan, which is part of the ongoing care for neuropathic pain management, must be available to the patient before discharge from rehabilitation, and the patient must be educated about its elements. The plan must also be provided to any post-discharge care providers at discharge and especially to the provider assuming primary management of the patient. Useful items to include in the discharge plan, depending on the complexity of the case and the team members involved in care, are current medication, a medication titration plan, a plan for future pain management, nonpharmacologic treatment modalities, scheduled ongoing rehabilitation visits, and suggestions for the timing of follow-up and re-referral to rehabilitation. As much as possible, a discharge plan should also remove barriers to accessing services and identify appropriate community resources for each patient. It is often possible to identify suitable resources by working with partner organizations and allied services.

It is essential to integrate the principles of self-management into the discharge plan and patient education, to support the maintenance of a patient’s function and stability of pain management after discharge. Self-management interventions commonly involve psychoeducation to develop or improve self-efficacy skills in goal setting, problem-solving, management of psychological consequences, medication management, symptom management, social support, and communication.

Techniques should be:

1. demonstrable or actionable by the individual,
2. matched to the individual’s abilities,
3. linked to further community support.

Evaluation of practice supports accountability and improvement. The subjective nature of pain and the challenging nature of successful pain management make continuous quality improvement critical to ensuring that the individual’s needs continue to be met and that resources are used appropriately. Essential elements of a quality improvement program are process and outcome indicators to demonstrate the status of practice change. Process indicators, such as monitoring measure implementation, should include intent and by target. Outcome indicators, such as a reduction in the intensity of an individual’s pain over time, should be measured using the International Spinal Cord Injury Pain Basic Data Set element on pain intensity to accurately assess change produced by practice activities.

Tramadol may be used for the reduction of neuropathic pain intensity among individuals with SCI. (Adapted from CANPAIN TREAT, p.S16; Level B)

Tramadol is recommended as second-line therapy for SCI-related neuropathic pain. A single randomized, placebo-controlled trial found a significant reduction in pain intensity with tramadol compared with placebo, but the evidence quality was downgraded because of wide confidence intervals. The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain is a useful resource for general information on opioid management and prescription considerations. Although tramadol is not a scheduled drug in Canada, in the United States, it is a Schedule IV drug.

The maximum daily dosage of tramadol is 400?mg, divided into up to four daily doses. Treatment is usually initiated at 50?mg QD or BID and titrated, based on efficacy and tolerability. Common adverse effects are sedation, nausea, and constipation. A slight increase in the risk of serotonin syndrome can be seen when tramadol is combined with other monoaminergic drugs such as tricyclic antidepressants.

Lamotrigine may be considered in those with incomplete SCI (AIS B, C, or D) for the reduction of neuropathic pain intensity. (CANPAIN TREAT, p.S16; Level B)

Evidence for the efficacy of lamotrigine has been demonstrated only in patients with incomplete SCI. As a result, lamotrigine is recommended as second-line therapy only in this population. One randomized placebo-controlled trial showed that lamotrigine significantly reduced the intensity of neuropathic pain for patients with incomplete SCI, but the evidence quality was downgraded because of wide confidence intervals.

Lamotrigine dosage was titrated to a maximum of 400?mg per day. Common adverse effects were dizziness, somnolence, headache, and rash. It should be noted that lamotrigine has a black box warning issued by the United States Food and Drug Administration (FDA) for serious skin rashes, including Stevens-Johnson Syndrome.

Transcranial direct current stimulation (tDCS) may be considered for reducing neuropathic pain intensity among individuals with SCI. (CANPAIN TREAT, p.S16; Level A)

tDCS is recommended as third-line therapy for patients with SCI-related neuropathic pain on the basis of four RCTs focused on neuropathic pain in patients with SCI. Minor side effects of tDCS include skin irritation, which can be minimized by preparing electrodes with saline and the skin with electrode cream and by increasing current gradually, and phosphene, the visual perception of a brief flash of light, which is not actually present, if an electrode is placed near the eye.

Combined visual illusion and transcranial direct current stimulation may be considered for reducing neuropathic pain intensity among individuals with SCI. (CANPAIN TREAT, p.S17; Level A)

The combination of visual illusion and tDCS is recommended as third-line therapy. The main side effects of this combined therapy included mild headache and fatigue.

The dorsal root entry zone (DREZ) procedure may be considered in exceptional circumstances and as a last resort for reducing neuropathic pain intensity among individuals with SCI. (CANPAIN TREAT 2016, p.S17; Level C)

Evidence of benefit for the DREZ procedure exists, but the risk of the procedure does not justify its use beyond exceptional circumstances. Risks associated with the DREZ procedure include paresis, neuropathy or radiculopathy, ataxia and a variety of surgical complications such as persistent incisional site pain, cerebrospinal fluid leak, wound infection, subcutaneous hematoma, and bacteremia.