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History
Will help determine whether the character & distribution of pain follow the neuropathic criteria & whether a relevant lesion or disease in the nervous system is probably responsible for the pain
Pain Intensity
Can be rated using a valid verbal, numerical or visual analog scale or Numeric Pain Rating Scale such as the Neuropathic Pain Scale & Neuropathic Pain Questionnaire
Assessed at each visit to monitor therapeutic response
Description of Sensory Symptoms
Quality of pain: burning, sharp, stabbing, cold, allodynia, hyperalgesia, spontaneous, dysesthesia, paresthesia
Frequent non-painful sensations: pricking, tingling, aching, numbness, hypoesthesia, anesthesia, hypoalgesia, analgesia
Sensory abnormalities & pain paradoxically co-exist
Temporal Variation of Pain
Pain usually becomes worse toward the end of the day
Rule out a neoplastic process if pain progressively increases over the recent months
Functional Impact
Impact on sleep, self-care, daily activities, work, social & sexual dysfunction, mood & suicidal ideas
Previous Treatment
Usually resistant to medications (eg Paracetamol, NSAIDs)
Adequate titrated doses of specific drugs should be determined & documented
Alcohol & Substance Abuse
History of dependence disorders can affect decision about prescribing opioids & cannabinoids
Consider interaction of sedatives & alcohol w/ other substances
Spontaneous Pain or Sensation
Paresthesias (eg tingling, itching, sensation of something crawling on one’s skin, discomfort of one’s foot “falling asleep”)
Dysesthesias (eg pricking, electric shock-like, burning or shooting pain)
Phantom pain
Stimulus-Evoked Pain or Sensation
Allodynia
Hyperalgesia
Hyperpathia
Hypoesthesia/Anesthesia
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Physical Examination
Allows integration of the patient’s current symptoms & localization of the involved elements of the nervous system
Identifying pain localization, quality, intensity & pattern is essential
Reveals the presence of negative (loss of function) & positive (hyperalgesia &/or allodynia) signs for sensory modalities affecting the somatosensory system & relevance to the underlying disease or lesion
Motor Examination
May reveal motor weakness in the distribution of the involved nerve
Deep Tendon Reflex
May be decreased or absent in the distribution of affected nerve
Sensibility Examination
Reduced or absent light touch, pin prick, vibration responses & proprioception in the affected nerve territory
Sensory disturbances can expand outside the area of nerve innervation
Dynamic allodynia: pain arising from gentle brushing of skin w/ cotton ball
Thermal allodynia: burning sensation due to an ice cube placed on the skin
Hyperalgesia to a pin prick test
Pain on leg lifting: irritation of lumbar nerve roots
Myofascial trigger points: myofascial pain plus neuropathic pain
Skin Examination
Changes in skin temp, color, sweating or hair growth (complex regional pain syndrome)
Residual dermatomal scars persisting after herpes zoster infection
Characteristic skin changes of DM
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Ancillary Tests
May be conducted to document the presence of a specific underlying neurologic disease or confirm a sensory lesion w/in the pain distribution
Laboratory Tests
Quantitative means to measure objective response
Neurophysiological Testing
Standard neurophysiological responses to an electrical stimulus can identify, localize & quantify damage along peripheral or central sensory pathways
Pain-related evoked potential:
Laser-evoked potentials are the easiest & most reliable methods for assessing function of the nociceptive & A-delta fiber pathways in patients w/ NP
Electromyography & Nerve Conduction Velocity (EMG/NCV):
Provides objective evidence of nerve injury or dysfunction but primarily evaluates the large myelinated fibers thus small fiber neuropathy may not be ruled out if the result is normal
Microneurography:
Provides valuable information on the physiology & pathophysiology of all nerve fiber groups but this is not recommended as routine procedure for assessing patients w/ peripheral NP
Pain-related reflexes:
Diagnostically useful only for facial pains as in trigeminal pain disorders
Skin Biopsy
Best tool for assessing neuropathies w/ distal loss of unmyelinated nerve fibers
Recommended in patients w/ painful or burning feet of unknown origin & w/ clinical impression of small fiber dysfunction
Additional Tests to Identify Other Causes of Neuropathies
Glucose tolerance test
Thyroid function
Vitamin B12 levels
CD4+ T-lymphocyte counts
Lumbar puncture
Quantitative Sensory Testing
Psychophysiological measure of perception in response to external stimuli of controlled intensity, which allows documentation of sensory profile
Appropriate to quantify positive sensory phenomena like mechanical & thermal allodynia & hyperalgesia which may help characterize painful neuropathic syndromes & predict or monitor treatment effects
Functional Neuroimaging
Functional neuroimaging studies are encouraged in patients w/ NP
Computed Tomography (CT) Scan
Facilitates specific diagnosis
Three-Phase Bone Scan
May help in the diagnosis of complex regional pain syndrome
Positron Emission Tomography (PET)
Measures cerebral blood flow or metabolic activity in defined brain regions
Magnetic Resonance Imaging
Can identify small patches of inflammation in peripheral nerves
Activation Studies
Investigate local synaptic changes specifically associated w/ a given task or a particular stimulus by comparing statistically activated & controlled conditions
Screening & Assessment Tools
The main advantage is to identify potential patients w/ NP, particularly by non-specialists
Screening Tools
Unidimensional scales
McGill Pain Questionnaire
Douleur Neuropathique en 4 (DN4) Questions
ID-Pain
Pain DETECT
Leeds Assessment of Neuropathic Symptoms & Signs
Standardized Evaluation of Pain
Chinese Identification Pain Questionnaire
Assessment Questionnaires
Brief Pain Inventory
Neuropathic Pain Scale
Neuropathic Pain Symptom Inventory
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