Nerve Pain

September, 2006

Definition of the Problem
There are three major classifications of nerve pain: neuritis, neuralgia, and neuropathy.

Neuritis is a term used to describe an inflammation of a nerve that results in pain, sensory disturbance, or the ability of the nerve to “react” properly. Among the many types of neuritis are optic, interstitial, and brachial.

Neuralgia is characterized by shooting or sudden and recurring pain involving a nerve or nerves. It usually does not involve permanent damage or structural change to the nerve. Some types of neuralgia are migranous, cervico-occipital, post-herpetic, and ideopathic. Trigeminal neuralgia in the face (formerly, tic douloureux) is considered by many to be the worst possible pain anyone can experience.

Neuropathy (also known as peripheral neuropathy, sensory peripheral neuropathy, or peripheral neuritis) is a painful condition that usually results from major or irreversible damage to the nerves. This damage can be from disease, injury, or a tumor. In the United States, diabetes is the leading cause of neuropathy. Most people with neuropathy experience periodic or constant muscle weakness, numbness, and tingling. Many also experience severe burning or electric-like shooting pain.

Scope and Cost of the Problem
According to the Neuropathy Association, neuropathy affects between 15-20 million Americans (What Is Neuropathy, 2006).

Total disease-related costs of diabetic neuropathy alone are estimated at $10.91 billion a year (Gordois, Schuffham, et al, 2003). Approximately 43% of those with neuropathic pain reported that their employment was affected by their condition, with significant reduction in their quality of life, and an increase in comorbid conditions such as sleep deprivation, coronary heart disease, depression, and anxiety (McCarburg and Billington, 2006).

Medical Treatment
Treatment of nerve pain is often geared toward relieving symptoms. No one therapy is completely successful, and it is not uncommon for two and three drugs to be used. Specific treatment is usually determined by the exact condition. For example, neuritis is treated with opiates, steroids, and NSAIDs. For neuralgia, carbamazepine is a frequent first treatment choice. Baclofen, clonazepam, gabapentin, and valproic acid have also been known to be somewhat effective.

Most neuropathic pain is treated with any number of drug types: tricyclic antidepressants (TCA’s); anticonvulsants such as gabapentin; systemic local anesthetics; SSRI’s; corticosteroids; substance P depletors; autonomic drugs; NMDA receptor antagonists; and capsaicin cream. When these treatments fail, other interventions include trigger-point injections, pain “blocks,” epidural steroids, spinal cord stimulators, TENS stimulation, and morphine pumps. Surgery is rarely recommended.

Other Treatments for Nerve Pain
In addition to medication, physical therapy, weight loss, aerobic exercise, muscle group strengthening, and nutritional supplements are sometimes recommended. Psychological approaches, including behavior modification and respondent treatment (hypnosis, visualization, relaxation, and biofeedback) are frequently recommended (Galper, Taylor, Cox, 2003; Irving, Goli, Dunteman, 2004; Mackey, undated; Richeimer and Macres, 2000; Yung and Bruehl, 2003).

Mind-Body Approaches
Since stress can aggravate pain, stress reduction is an indispensable part of any nerve pain treatment plan. This is one of the areas where mind-body techniques are particularly effective (Blumenthal, Jiang, et al, 1997; Williams, Kolar, et al, 2001). There is also substantial evidence to support the use of mind-body techniques in the management of many types of pain. The effectiveness of guided imagery is well documented (Ilacqua, 1994; Lambert, 1999; Mannix, Chandukar, et al, 1999), as are hypnosis (Crasilneck, 1995; Haanen, Hoenderos, et al, 1991; Tusek, Church, et al, 1997), meditation (Kabat-Zinn, Lipworth, and Burney, 1985), and biofeedback (Buckelew, Conway, et al, 1989).

Guided imagery involving relaxation and positive suggestion can help to lower stress, improve coping skills, enhance an overall sense of emotional well-being, and help with making lifestyle changes.

Blumenthal JA, Jiang W, Babyak MA, Krantz DS, Frid DJ, Coleman RE, Waugh R, Hanson M, Appelbaum M, O'Connor C, Morris JJ. Stress Management and Exercise Training in Cardiac Patients with Myocardial Ischemia: Effects on Prognosis and Evaluation of Mechanisms. Archives of Internal Medicine. 1997 157: 2213-2223.

Buckelew SP, Conway R, Parker J, Deuser WE, Read J, Witty TE, Hewett JE, Minor M, Johnson JC, Van Male L, McIntosh MJ, Nigh M, Kay DR. Biofeedback/Relaxation Training and Exercise Interventions for Fibromyalgia: A Prospective Trial. Arthritis Care Res. 1989 Jun;11(3): 196-209.

Crasilneck HB. The use of the Crasilneck Bombardment Technique in problems of intractable organic pain. Am J Clin Hypn. 1995 Apr;37(4):255-66.

Galper DI, Taylor AG, Cox DJ. Current status of mind-body interventions for vascular complications of diabetes. Fam Community Health. 2003 Jan-Mar;26(1):34-40.

Gordois A, Schuffham P, Schearer A, Oglesby A, Tobian JA. The health care costs of diabetic nephropathy in the United States. Diabetes Care. 2003;26:1790-1795. Qtd in McCarberg B, Billington R. Consequences of Neuropathid Pain: Quality-of-life Issues and Associated Costs. Am J Manag Care. 2006;12: S263-S268.

Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP, Hekster GB. Controlled Trial of Hypnotherapy in the Treatment of Refractory Fibromyalgia. J Rheumatol. 1991 Jan;18(1): 72-5.

Ilacqua GE. Migraine headaches: coping efficacy of guided imagery training. Headache. 1994 Feb;34(2):99-102.

Irving G, Goli V, Dunteman E. Novel pharmacologic options in the treatment of neuropathic pain. CNS Spectr. 2004 Oct;9(10 Suppl 10):1-11.

Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine. 1985 June; 8(2):163-90.

Lambert SA. Distraction, Imagery and Hypnosis. Techniques for Management of Children’s Pain. J Child Fam Nurs. 1999 Jan-Feb;2(1) :5-15

Machey S. Improving Quality of Life When Battling Diabetic Peripheral Neuropathy. PDF presentation, slide 4.
Accessed September, 2006

Mannix LK, Chandurkar RS, Rybicki LA, Tusek DL, Solomon GD. Effect of guided imagery on quality of life for patients with chronic tension-type headache. Headache.1999 May;39(5):326-34.

McCarberg B, Billington R. Consequences of Neuropathid Pain: Quality-of-life Issues and Associated Costs. Am J Manag Care. 2006;12: S263-S268.

Richeimer SH, Macres SM. Understanding Neuropathic Pain. 2000.
Accessed September, 2006.

Shenefelt PD. Hypnosis in dermatology. Arch Dermatol. 2000 Mar;136(3):393-9.

Tusek DL, Church JM, Strong SA, Grass JA, Fazio VW. Guided imagery: a significant advance in the care of patients undergoing elective colorectal surgery. Dis Colon Rectum. 1997 Feb;40(2):172-8.

[no authors listed] What Is Neuropathy? Neuropathy Association, 2006.
Accessed September, 2006.

Williams KA, Kolar MM, Reger BE, Pearson JC. Evaluation of a Wellness-Based Mindfulness Stress Reduction intervention: a controlled trial. American Journal of Health Promotion. 2001 July-Aug; 15 (6): pp.422-432.

Yung Chung O, Bruehl SP. Complex Regional Pain Syndrome. Curr Treat Options Neurol. 2003 Nov;5(6):499-511.