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4.4: Neuropathic Pain

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    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., 2020; Bove 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.

    Table \(4.4.1\) 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
    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

    Table \(4.4.2\) 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 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 dorsifelxion & 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., 2016; Bove 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., 2017; Gilbert 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)

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